Affiliate Dermatologist Membership Application

Member Application Form

Please note. All fields marked with an asterisks (*) are required.

Professional Details

Title *

First Name *

Last Name *

Date Of Birth *

If you have or work at more than one clinic, please put your main clinic here, you will have opportunity to add further clinics in your Member profile once your application has been accepted

Hair Transplant Clinic Name *

Clinic Address

Street Address *

Address Line 2

City *

ZIP / Postal Code *

Country *

Clinic Tel No: *

Clinic e-mail address

Clinic / Work Website

Qualifications

Qualifications *

GMC Registration Number: *

Dermatology Experience *

Personal Contact Details

Street Address *

Address Line 2

City *

ZIP / Postal Code *

Country *

Personal e-mail *

This email address will be used for all communications with the BAHRS. From time to time sensitive information will be sent to this address, please ensure it is secure.

Referee's name *

NB: Referee must be a BAHRS surgeon member

Tel No *

The BAHRS member who recommended I join the BAHRS

Date *

I confirm that I have read and understood the BAHRS Membership Terms and Conditions, and agree to abide by them. *

I confirm that I have read and understood the BAHRS Code of Conduct for Affiliate Dermatologist Members, and agree to abide by them. *

Your data will not be shared with any third party, and the principles of the GDPR 2018 and will be adhered to. The BAHRS will use your personal data for the purposes of your involvement in Association activities. I understand that by submitting this form I am consenting to receiving information about the BAHRS by post, email, online or by phone. *

Your application will not be processed until confirmation of support from the referee is received at president@bahrs.co.uk

An invoice will be sent for the annual membership fee upon approval. NB. Annual membership runs for 12 months from date of payment.