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Complete and send this form to request physician initial application:
*Please fill in all the information.  It is very important that we have a way to contact you for questions related to your application. 
Physician Information:
Last Name: 
First Name: 
Current Address:
City:
State:
Zip:
Best Way to Contact: 
Alternate Contact:
Name:
Phone:
Practice Information:
Practice You Are Joining:
Anticipated Start Date:
Privileges You Are Requesting:
(Hold down the "control" key to select more than one.)
By clicking "Send to Medical Staff Office," you are electronically signing this form and e-mailing your request to the Memorial University Medical Center Medical Staff/Credentialing Office.

If you have any questions, please contact Yvonne Warbington, CPCS, in the Medical Staff/Credentialing Office at 912-350-6652.
Thank you.
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Memorial University Medical Center hospital campus: 4700 Waters Avenue, Savannah, GA 31404 - 912-350-8000