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Today's Date*

Date

Name*

First NameLast Name

Which best describes your phase of business?*

Opening a medspa: Just getting startedOpening a medspa: Doing a startup on my own, but I need helpEstablished medspa with revenue less than $600k per yearEstablished medspa with revenue less than $1MEstablished and expandingWe need help!I need compliance and regulatory guidance

Company Name, if established*

Company Website, if established*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

If opening a new medical spa, what is your budget from planning to launch to get you off the ground?

Email*

example@example.com

What best describes your current role in the practice?*

Education (Please select one)*

Please be as specific as possible in describing your education, licenses obtained, professional background. *

Please describe why you are looking for assistance from DAC.*

What strategies have you used to overcome any challenges you are experiencing?*

When would you like to begin working with us?*

Future Goals*

Open my own medical spaGrow my current practicePractice independentlyI am a current provider and looking to expand my education and servicesI am interested in a Mobile Aesthetic BusinessOther

Do you have an attorney (It's okay if you don't.)*

How will you fund your startup? (Select as many as you like.)*

Do you have a business plan? (It's okay if you don't.)

YesNo

Which are most important to you?*

Have you worked with any consultants or industry professionals before? if yes, which companies? Tell us about your experience.*

If you need aesthetic training, which are you interested in?

Laser Training & Certification CourseInjectables Training & Certification CoursePDO Training & Certification CourseSkin Expert Online CertificateAdvanced Aesthetics Online CertificatePRP & Microneedling Online CertificateNCLC Exam Prep & Safety Officer Training CertificationMedspa Trainer Online CertificateMedical Director Certification Program

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