Florida Board of Medicine » Application Request- Healthcare Practitioner Licensing and Regulation

If you are not able to obtain a paper version of your application when logged into your account, please complete this form to request that one be emailed to you.

Name *

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Last

Email *

Profession *

License Number

Type of Application

Initial Application
Renewal Application

Last 4 Digits of SSN *

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NOTE: To protect your privacy, please do not disclose or share any sensitive or confidential health and financial related information within this form.

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