RSMD Skills Lab Registration
Provider Information
First Name
*
Last Name
*
Email
*
Phone
*
Select Credentials
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Medical License Number
*
State of Licensure
*
Driver's License or Passport
*
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Please upload a valid driver's license or passport
Currently practicing medical aesthetics?
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Practice/Clinic Name
Address
Street Address
City
State
Country
Country
Postal Code
Have you trained with Dr. Rebecca Small previously?
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Yes - Live RSMD Training Workshop
Yes - RSMD Online Courses
No - But I will have completed training prior to the Skills Lab*
*You must have completed RSMD Hands-on Workshop or completed all of the RSMD Upper Face Toxin Courses.
Date of training /course completion
Model Information
Model's Full Name
Model Email
Model Phone
Relationship to model
Treatment Plan
What areas are you planning to treat during the Skills Lab?
Frown lines
Forehead lines
Crow's feet
Brow lift
Lower eyelid wrinkles
Lip lines/lip flip
DAO
Chin
Masseter
Not sure yet
Learning Goals
Is there anything specific you would like guidance on during the Skills Lab? (Examples: dosing, symmetry, brow shaping, consultation approach).
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What topics or techniques would you like to learn in the future during a Hands-on Workshop or Skills Lab?
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Provider Acknowledgment
I confirm that I am a licensed medical provider authorized to perform botulinum toxin injections and understand that I will be responsible for treating my model during the Skills Lab while receiving supervision and guidance from Dr. Rebecca Small.
*
I acknowledge
Provider Signature
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