Treatment Model Registration Form

Patients Model Details

Fill the form below and we will get you confirmed as a model for one of our up and coming trainings. Treatment appointments are performed at Genesis Medspa located at 142 S Raven Mine Drive, Colorado Springs under the direction of Dr. Lisa Jenks. ****Please note that once you are registered as a model, you will not be scheduled until models are needed for the dates and or the treatment you register for. If you are not called, you will be kept in the model database for a later course date. WE DO NOT CALL TO SCHEDULE MODELS UNTIL TWO WEEKS BEFORE THE START OF EACH CLASS. MODELS ARE SCHEDULED ON A FIRST COME FIRST SERVE BASIS UPON REGISTRATION DATE.
Full Name*
Gender*
Phone Number
Date of Birth*

Day Month Year
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail Address
example@example.com
Have you previously been a training model with us before?*

YesNo
Which treatment are you interested in participating as a model for our students?

PDO Thread LiftBotoxCosmetic FillersLaser Hair RemovalLaser Vein RemovalPlasma Pen for facial skin tighteningLaser Skin RejuvenationLaser Peel
Please select the date (s) for the treatment you are interested in participating in as a model. Our reservation coordinator will be in contact with following the submission of this form to secure a specific appointment time during your prefered date.
Take Photo of your skin or area you would like to have treated. A photos is required to ensure you are qualified for the service.
Should be Empty:

Patients Model Details