Online registration should take 5 - 10 minutes to complete. For questions, please contact Stephanie at (407) 766-2955 or firstname.lastname@example.org.
*Note: No experience injecting neurotoxins or dermal fillers is required for this course. However, in order to participate in the hands-on portion, your indicated credentials will be confirmed.
Acknowledgment and Authorization for Hands-On Training
This form is required for Nurse Practitioners (NP) and Physician Assistants (PA) to have signed by their authorizing physician.
I have agreed to participate in an interactive hands-on training session with a Face-Time Aesthetics Training instructor.
As part of my participation in the educational program, I will practice injection techniques on a volunteer patient/model (the “Volunteer”) that I personally prescreened and selected. I represent and warrant that the patient/model is an appropriate candidate for treatment and that I will use my own legally acquired United States FDA approved injectable agents. In order to verify the above, I agree to provide pedigrees, invoices, and chains of custody forms to Face-Time Aesthetics Training upon request. All documents will be available for review prior to beginning the training session(s). Failure to have the documents on hand may result in the cancellation without refund of the training session.
I understand the risks inherent in facial injections and aesthetic medicine and I hereby assume all responsibility of any kind which may arise in connection with my performance of facial injections, including any or all of my acts and omissions in connection therewith.
I agree to indemnify, defend, and hold harmless the instructor and Face-Time Aesthetics Training, as well as each of their respective affiliates, licensees, assigns, parents, subsidiaries and affiliated companies, and the officers, directors, shareholders, employees and agents of all such entities (all of the foregoing, collectively, the “Indemnitees”), from and against any and all costs, losses, liabilities, damages, and expenses, including reasonable attorneys’ fees and costs, arising out of any claim, complaint, challenge, proceeding, or other action, whether by the patient/model or otherwise, resulting from or arising out of my participation in the training session.
I further agree to waive any and all claims of any kind that may arise with respect to the instructor and Face-Time Aesthetics Training in connection with my participation in the training session.
I understand and agree that the instructor will only offer his/her personal medical opinion regarding the injection sites, amounts, and course of treatment and all final decisions regarding whether or not to adhere to or follow such recommendations are my own independent medical judgments. Further, I understand that neither the instructor nor Face-Time Aesthetics Training are responsible for any adverse reactions or outcomes which may befall the patient/model and the instructor will not perform or assist in the performance of any injection or other procedure. Finally, I understand and agree that the instructor may or may not be licensed to practice in the state in which the course is given.
I certify that I notified and obtained the consent of my professional liability insurer to receive this training and such policy will cover any act or omission committed by me during the training. As a prerequisite to my participation in the training, I agree to provide a copy of my professional liability coverage to Face-Time Aesthetics Training. Further, I obtained a signed Patient Acknowledgement and Waiver of Liability from my patient/model and have explained that even if the procedures take place at Face-Time Aesthetics Training’s facility, or another location secured, rented, or leased by Face-Time Aesthetics Training, I am fully responsible for any and all outcomes or complications related to the training.
Finally, I represent and warrant that I hold a current license in the state in which the course will take place and where I will be performing procedures, and undergoing training, and with this license I am legally able and plan to perform facial and/or aesthetic injection procedures, and have provided evidence of such qualifications. If training outside my state of licensure, I certify that I fall within the scope of practice for my credentials in the state in which this program is being held for training purposes only and have provided such evidence.
Please read this policy in full and agree below.
Please note: All cancellations must be emailed to email@example.com.
A refund will be given, less a $250.00 administrative/processing fee if canceled 14 days or more prior to the start of the course. Any cancellation less than 14 days or "No Shows" will not qualify for a refund. Due to this policy, weather-related cancellations are considered "No Shows" if the program is conducted. Please note Face-Time Aesthetics Training is not responsible for deposits to hotels, fees associated with necessary airline changes or non-refundable airline tickets.
Once your registration is completed, you will receive an email confirmation.
Once you submit this page, your registration information will be sent to the Face-Time Aesthetics Training. Please contact Stephanie at (407) 766-2955 or firstname.lastname@example.org for payment options.
COURSE TITLENeurotoxins & Dermal Fillers Foundations II