Private & Group Training Application
Private and small-group training for up to three participants. Pricing depends on your topics, format, and number of participants. Share your request and we will send a personalized quote.
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
Credentials
*
Please Select
RN
NP
PA
MD
DO
Dentist
License Number
*
License Issuing State
*
Are you currently practicing?
*
Yes
No
Practice name and city
Show only when you answer Yes
Aesthetics Experience
*
Under 1 year
1 to 3 years
3+ years
Experience details
Basic injector course completed: course name, provider and year
*
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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.
Do you have a medical director?
Yes
No
Medical Director Name
Medical Director Contact (email or phone)
My medical director has confirmed in writing that they approve me injecting in another state
My medical director has confirmed in writing that they approve me injecting in another state
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.
Malpractice Insurance Carrier
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Your Training
Format
*
Private
Group
Number of participants
Preferred dates
*
Topics of interest
*
Neurotoxins
Dermal filler by area, including temples, chin, and lips
Cannula technique
Full facial balancing
PRP/PRF EZ Gel for the under-eye area
Biostimulators, including Sculptra and Radiesse
Complication management
Other
Your training goals
*
Location
*
At the Academy
At my practice
Practice address
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Final Details
T-shirt or hoodie size for each participant, XS to XXL
How would you like to pay?
*
Full payment
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.
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Request Custom Training
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