RSMD Skills Lab Registration

Provider Information

First Name *

Last Name *

Email *

Phone *

Select Credentials *

Medical License Number *

State of Licensure *

Currently practicing medical aesthetics? *

Practice/Clinic Name

Address

Street Address

City

State

Country

Postal Code

Have you trained with Dr. Rebecca Small previously? *

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

Learning Goals

Is there anything specific you would like guidance on during the Skills Lab? (Examples: dosing, symmetry, brow shaping, consultation approach).

What topics or techniques would you like to learn in the future during a Hands-on Workshop or Skills Lab?

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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