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AOPA BasicMed Physician Directory Consent Form

*PLEASE NOTE!* Once you have completed and submitted this form, your listing will not show up immediately in the doctor finder database. We typically get your listing validated and uploaded to the live database within 1-2 business days.

Thank you for your interest in joining the Aircraft Owners and Pilots Association’s public directory of state-licensed physicians who are available to perform BasicMed examinations.

For the Aircraft Owners and Pilots Association (AOPA) to share your information with the public and publish it in our directory, it is important that we receive your consent to do so. AOPA’s use of the information that you provide is not a recommendation or endorsement of you by our association. The information you provide is offered to the public free of charge as a resource to assist pilots in locating nearby physicians.

If corrections are required to any information provided below, or you wish to withdraw this consent, please email [email protected] with your request.

Please acknowledge the following:

Physician Qualifications

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_68-1A.pdf

I consent to AOPA including the following information about me in the directory:

Please check the required acknowledgement boxes in the first section before continuing.