2 DAY COURSE - ART OF INJECTION ACADEMY

2 DAY COURSE - Art of Injection Academy - Registration Form
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Company
What 2 day course are you registering for?
Do you have an NPI #?
NPI OR LICENSE NUMBER:
Medical Credentials:
For example: MD, RN, NP, PA, etc
Once you completed the form above, please copy the link below or scan the QR code above to pay $4000 for the 2 Day Course (Botox and Filler) training to be fully registered.

https://link.clover.com/urlshortener/6KhwV3
If you registered & paid for the 2 Day Course - you just completed the form.

If you would like to register to 1 of the Course Days, please continue and register the bottom portion to be fully registered!
If you are interested to join 1 Day instead of the 2 Day Course, please mention what day you would like to come to below. To fully Register please copy the link below or scan the QR code below to pay $2500.

https://link.clover.com/urlshortener/DVCn5F
Choose which day you would like to register to for the 1 Day Course:
Any Questions?
Should be Empty:

2 DAY COURSE - Art of Injection Academy - Registration Form