Neurotoxin & Dermal Filler 2-Day Course Application
$3,800 per student. One fee covers both days of training, all product and supplies, live models, meals, course materials, and your complimentary shadow day ($500 value). We review every application and follow up with upcoming course dates and next steps.
Personal Information
First Name
*
Last Name
*
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Credentials & Experience
Are you currently practicing?
*
Yes
No
Credentials
*
Please Select
RN
NP
PA
MD
DO
Dentist
License Number
*
License Issuing State
*
If yes, where? Practice name and city
Aesthetics Experience
*
Under 1 year
1 to 3 years
3+ years
Experience details
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Do you have a medical director?
Yes
No
Out-of-State Providers
Only complete this section if you practice outside Indiana. If you have a medical director, they must confirm in writing that they approve you injecting in another state. Everyone must carry their own malpractice insurance.
Medical Director Name
I understand that without a medical director, I must carry my own medical malpractice insurance that covers me out of state.
*
I understand that without a medical director, I must carry my own medical malpractice insurance that covers me out of state.
Medical Director Contact (email or phone)
My medical director has confirmed in writing that they approve me injecting in another state
Yes
Malpractice Insurance Carrier
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Payment & Final Details
How would you like to pay?
*
Pay in full
Split payments
How many months would you like to split your payments over?
*
Payment plan duration is subject to approval. Split payments include an additional $50 per invoice.
Anything else you'd like us to know?
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