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: (800) 714-4811
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.