RSMD Model Submission Form
Model Requirements for Teaching and Training:
Please note that models will be used for teaching and training purposes, and we require participants who have not previously been seen or treated by Dr. Small or any providers at RSMD Medical Aesthetics. All models must be at least 18 years old and willing to undergo treatment in front of others, while being filmed and photographed. Most filming occurs on Wednesday, so availability during that time is essential.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of birth (Must be 18 years or older)
*
-
Month
-
Day
Year
Date
Have you ever had botulinum toxin? If yes, please be sure to answer toxin questions below.
*
Yes
No
Where have you received botulinum toxin treatments? (Select all that apply)
Frown lines
Horizontal forehead lines
Crow's Feet
Lower eyelid wrinkles
Eyebrow lift
Bunny lines
Lip lines
Gummy smile
Marionette lines
Chin
Masseter
Neck
Axillary hyperhidrosis
Chest lines
Nasal tip lift
Facial asymmetry
Other
When was your last botulinum toxin treatment?
Which area(s) are you interested in treating with botulinum toxin? (Select all that apply)
*
Frown lines
Horizontal forehead lines
Crow's Feet
Lower eyelid wrinkles
Eyebrow lift
Bunny lines
Lip lines
Gummy smile
Marionette lines
Chin
Masseter
Neck
Axillary hyperhidrosis
Chest lines
Nasal tip lift
Facial asymmetry
Other
Have you ever received dermal filler treatments? If yes, please be sure to answer filler questions below.
*
Yes
No
Which areas have you had treated with dermal filler? (Select all that apply)
Nasolabial folds
Marionette lines
Mental crease/Extended
Chin augmentation
Lip border
Lip body
Lip lines
Malar (cheek) augmentation
Frown lines
Scars
Jaw line
Tear trough
Liquid rhinoplasty
Other
When was your last dermal filler treatment?
Which areas are you interested in having treated with dermal filler? (Select all that apply)
*
Nasolabial folds
Marionette lines
Mental crease/Extended
Chin augmentation
Lip border
Lip body
Lip lines
Malar (cheek) augmentation
Frown lines
Scars
Jaw line
Tear trough
Liquid rhinoplasty
Other
Are there any treatments or areas you're not comfortable with?
*
Images
Please upload images of the areas you would like treated. Ensure you include both a static image and a dynamic image for each area.
*
Browse Files
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Sample images
If I am chosen to be a model, I consent to a media release, allowing the use of my image, likeness, and/or recordings in promotional materials and publications.
*
Yes
No
By clicking submit, I confirm that all the information provided is accurate to the best of my knowledge.
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