PRIMA Membership Application and Renewal Form

Thank you for your interest in joining or renewing your membership with the Philippine Regenerative & Integrative Medical Association (PRIMA).

Doctors interested in the PRIMA Training Program must complete this membership form because the program is available only to current and approved PRIMA members.

Membership questions: Dra. Ma. Judea Millora — 0917 880 3522

Data Privacy Notice and Consent

Please read the notice before continuing.

DATA PRIVACY NOTICE AND CONSENT

The Philippine Regenerative & Integrative Medical Association (PRIMA) respects and protects your right to privacy in accordance with Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012, its Implementing Rules and Regulations, and relevant issuances of the National Privacy Commission.

By completing this application form, you acknowledge that PRIMA may collect, use, store, and process the personal information you provide. This may include your name, contact details, professional information, medical licence details, clinic or institutional affiliations, educational background, training credentials, uploaded documents, and other information necessary to evaluate and process your membership application.

The information collected shall be used:

To evaluate and process your application for PRIMA membership;
To verify your professional credentials and eligibility;
To communicate with you regarding your application, membership status, events, training programs, announcements, and official PRIMA matters;
To maintain PRIMA membership records and directories; and
To comply with applicable legal, regulatory, administrative, and organizational requirements.

Your personal information shall be accessible only to authorized PRIMA officers, committee members, secretariat personnel, and designated representatives who require access to process your application or maintain membership records. PRIMA shall implement reasonable organizational, technical, and administrative measures to protect your information against unauthorized access, disclosure, alteration, loss, or misuse.

Your information may be retained for as long as necessary to fulfil the purposes stated above, maintain membership records, and comply with applicable legal, regulatory, or organizational requirements.

You have the right to access, correct, or update your personal data; object to its processing; or request its deletion, subject to applicable laws and PRIMA policies. Privacy-related concerns may be submitted through PRIMA’s official contact channels.

By selecting “I Agree,” I confirm that I have read and understood the Data Privacy Notice and voluntarily consent to PRIMA’s collection, use, storage, and processing of my personal data for the purposes stated above. * I Agree I Do Not Agree

Please select an option.

We respect your decision. However, PRIMA cannot evaluate or process a membership application without the required consent to process your information.

Personal Information

Fields identified as public may be included in the PRIMA membership directory only after approval.

Last Name * Public directory field

First Name * Public directory field

Middle Name Optional; public directory field

Suffix Optional; public directory field

Personal Contact Number * Private; for internal PRIMA communication only

Membership Status

Select the application that best describes your purpose.

What type of application are you submitting? * I am applying to become a NEW member of PRIMA. I am RENEWING my PRIMA membership and do not need to update my existing public directory information. I am RENEWING my PRIMA membership and would like to update my information in the PRIMA public directory. I am applying for the PRIMA Training Program and understand that my membership must first be approved.

Please select your application type.

Professional and Contact Information

Provide information that PRIMA can use to verify your professional eligibility.

Email Address *

PRC Registration Number * Professional verification and public directory field

Home or Mailing Address * Private; internal records only

PMA Number

Current Medical Specialty and Professional Society *

Board Certification Diplomate Fellow None Other

Please specify

Upload a 2×2 Professional Photograph * Recent JPG or PNG, maximum 5 MB. Preferably wearing a doctor’s white coat against a white or neutral background. The photograph may be included in the public PRIMA directory after approval.

Clinic or Office Information

This information may be included in the approved PRIMA member directory.

Primary Clinic or Office Name *

Primary Clinic or Office Region *

Specify the region or country

Primary Clinic or Office Address *

Clinic Website or Social-Media Link *

Clinic Contact Number *

Secretary or Assistant’s Name and Contact Number * I confirm that I have permission to provide and publish this person’s contact information, or I entered “None.” *

Areas of Specialization *

Please specify

Please select at least one area of specialization.

What services do you offer in your clinic? * Use a concise, patient-friendly description. Avoid unsupported medical claims.

Educational and Professional Background

Enter “None” where a required item does not apply to you.

How did you learn about PRIMA, or who referred you? *

Medical School Graduated From *

Year Graduated *

Degree or Degrees Obtained *

Postgraduate Training * List the program, institution, and year completed. Enter “None” if not applicable. This may be included in the public directory.

Professional Society Affiliations * Include the society or organization, year joined, membership status, and any position held. Enter “None” if not applicable.

Other Hospital or Clinic Affiliations * List affiliations other than your primary clinic or office. Enter “None” if not applicable.

Membership Dues and PayPal Payment

Your correct dues will be calculated automatically from your application type and clinic location.

Philippine-based Applicants

PHP 7,500
Annual NEW Membership, including membership and induction fees

PHP 3,500
Annual RENEWAL Membership

Applicants Outside the Philippines

USD 150
Annual NEW Membership, including membership and induction fees

USD 100
Annual RENEWAL Membership

Your calculated membership dues: Select your application type and region above

After clicking the button below, your application will be saved and you will be securely redirected to PayPal. Your membership remains subject to PRIMA’s credential verification and approval.

I certify that the information and documents I have provided are true, complete, and accurate. I understand that submission does not guarantee membership approval and that PRIMA may verify my professional credentials. *