First Name *

Last Name *

Clinic Name *

Phone *

Email *

Website (If Applicable)

Instagram Handle *

What aesthetic qualifications do you currently hold? *

How many years have you been practising in aesthetics? *

Who did you complete your fibre-optic laser training with? *

When did you complete this training? *

Have you completed any refresher or advanced fibre training since? *

Yes

No

If yes, please specify

Approximately how many fibre-optic laser treatments have you performed to date? *

Do you currently own a compatible fibre-optic diode laser device? *

Do you hold valid aesthetic insurance? *

Yes

No

Who are you insured with? *

Why are you interested in becoming an authorised EndoLaze® practitioner? *

Are you currently offering treatments marketed as “Endo/lift/pulse/shape" etc or similar laser skin-tightening procedures? *

Yes

No

How do you currently position your clinic? *

How would EndoLaze® elevate your clinic brand and treatment offering? *

When would you realistically be ready to begin the licensing process? *

Are you prepared to follow structured protocol, marketing guidance and brand positioning requirements? *

Yes

I would like more information

Are you open to regional territory agreements where applicable? *

Yes

No

I understand that EndoLaze® is a registered trademark. *

Yes

I understand that authorisation is granted at the discretion of the EndoLaze® brand. *

Yes

I confirm that all information provided above is accurate. *

Yes

Regional Protection Notice

Regional protection may be granted subject to availability and ongoing compliance with EndoLaze® standards.

Territory agreements, where applicable, remain conditional upon performance, adherence to protocol and brand alignment.

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