Physician Authorization Form

Physician Authorization Form
This form must be completed for each PA, NP, or RN or other non-independent practitioner registering for an Aesthetic Advancements’ course.

Aesthetic Advancements, Institute
2700 Braselton Hwy, Suite 10-450
Dacula, Georgia 30019
Phone: (770) 365-3319

RE: Acknowledgement and Authorization for Hands-On Training. Please complete for each PA, NP, or RN registering.

I attest by my signature that I am the supervising physician for the participant listed below and that he/she practices under my supervising authority.

I hereby confirm that I am aware that the participant listed below is participating in an instructional course on the proper administration of:

Neurotoxins (BoNTA)/Dermal Fillers

I further understand he/she will be providing patient treatment during the hands on portion of the course. I understand and give my permission, as the supervising physician, that the treatments will be provided by the participant listed below and will be performed outside of my presence.
Participant Name and Credentials*
Sally Smith, RN
Location of Course*
City, State
Date of Course*

MonthDayYear
Date
Practice Name*
Practice Address*

Street Address

Street Address Line 2

CityState

Zip Code
Practice or Physician Email Address*
example@example.com
Supervising Physician Name & Credentials*
Supervising Physician Signature*

Clear
Sign with your finger or a stylus pen equipped for use on a screen/computer.
Today's Date*

MonthDayYear
Date
Should be Empty: