Academy for Injection Anatomy Live Course Registration

Hands-On CME Course Registration

The Fear of Injections is the Fear of Anatomy™
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Participant Name & Credentials *

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Email
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Email *
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Cell Phone Number *

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Medical License # *
License State of Issue *
License Expiration Date *
Medical Specialty *
Practice Name *
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Practice Address *

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Years of Experience in Aesthetic Injecting *
What anatomical areas do you feel weak in regarding filler injections? *
What are your favorite areas to inject? *
What do you hope to learn during this course? *
CME INFORMATION
Participants in this course will receive 8.0 Category 1 CME/CE credits upon successful completion. CME/CE Credit provided by AKH Inc., Advancing Knowledge in Healthcare. For full accreditation information, please click here.

Disclaimer, Release and Indemnity Agreement
Attendance at the Academy for Injection Anatomy course does not guarantee that the enrolled licensed healthcare professional will be competent to perform a procedure. The certificate of completion provided to attendees who complete the course does not bestow any special credentialing. It is the responsibility of the licensed health care professional to understand and adhere to the laws and guidelines of the state in which they practice medicine or otherwise perform healthcare services. Attendees must also understand the scope of what their professional license allows or disallows in regards to the newly learned procedures.

For and in consideration of permitting me to attend and participate in the Academy for Injection Anatomy course, I voluntarily release, discharge, waive and forever relinquish any and all actions or causes of action for damages occurring to me, my patients, heirs, personal representatives and assigns, arising as a result of receiving instruction in the field of facial injection for facial aesthetic rejuvenation. I, for myself and my patients, heirs, personal representatives, and assigns, release, waive, discharge and relinquish any action or causes of action whatsoever which may later arise, and I agree that under no circumstances will I or my heirs, personal representatives, or assigns prosecute or present any claims for damages against Surek, LLC or Christopher C. Surek, D.O. for any cause of action arising out of the Academy for Injection Anatomy course, whether the same shall arise by the negligence of any person or otherwise.

I, for myself and my heirs, personal representatives, and assigns, agree that in the event any claim for damages shall be prosecuted against Surek, LLC or Christopher C. Surek, D.O., or their respective members, managers, officers, employees, agents, or affiliates (collectively, "Indemnitees") as a result of my actions, omissions, or negligence, to indemnify and hold harmless Indemnitees from any losses, liabilities, or negative results or outcomes whatsoever that a patient may suffer from my action or procedure, including the cost and expense of defending the same. Indemnitees may not in any way be blamed or held liable for violations committed by an attendee.

I agree not to copy or distribute in printed or digital format any course materials without the written permission of Surek, LLC. Further, I agree not to record, publish, or transmit (by means of video, audio, or any other means) any online or electronic course content or webinars without the written permission of Surek, LLC.

I ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND AM FULLY AWARE
OF THE LEGAL CONSEQUENCES OF SIGNING THIS INSTRUMENT.
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ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO COVID-19
I {participantName} have chosen to attend the Academy for Injection Anatomy course in facial injection (the “Course”) to be presented by Christopher C. Surek, D.O and Surek, LLC (collectively, ”Surek”).

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and, as a result, federal and state health agencies recommend social distancing. I recognize that Surek has put in place reasonable preventative measures aimed to reduce the risk of Course attendees becoming infected with COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of attending the Course. I hereby acknowledge and assume the risk of becoming infected with COVID-19 by attending the Course.

I understand that, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID-19 after the test.

I understand that possible exposure to COVID-19 from attending the Course may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death.

I understand that COVID-19 may cause additional risks, some or many of which may not be known at this time, in addition to the risks described herein.

I understand all the potential risks, including, but not limited to, the potential short-term and long-term complications related to COVID-19, and I would like to attend the Course.

By signing this form, I voluntarily assume the risk that I may be exposed to or infected with COVID-19 by attending the Course. I understand that the risk of becoming infected with COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Surek agents and other Course attendees.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, illness, disability, death, or damages or loss of any kind), that I may experience or incur in connection with my attendance at or participation in the Course (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless Surek, their employees, agents, and representatives, of and from any Claims, including all liabilities, claims, actions, damages, costs and expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Surek and their employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after attending the Course.

I ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND AM FULLY AWARE OF THE LEGAL CONSEQUENCES OF SIGNING THIS INSTRUMENT.
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Today's Date *

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Payment Information
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DEPOSIT
$850 deposit required upon submission of registration

BALANCE
The $3000 balance must be paid 2 weeks prior to the live course date. We will contact you directly to collect the remaining balance payment.

Please note, the $850 deposit for this training is NON REFUNDABLE. For questions, please contact us at injectionanatomy@gmail.com.

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Academy for Injection Anatomy Live Course - DEPOSIT $ 850.00

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Hands-On CME Course Registration

Disclaimer, Release and Indemnity Agreement

ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO COVID-19

Payment Information