RSMD Hands-on Toxin Registration

Provider Information

First Name *

Last Name *

Email *

Phone *

Select Credentials *

Specialty *

Medical License Number *

State of Licensure *

Currently practicing medical aesthetics? *

Years practicing aesthetics: *

Years practicing medicine: *

Practice/Clinic Name

Address

Street Address

City

State

Country

Postal Code

Training Background

Why did you choose this training? *

Have you ever taken a hands-on botulinum toxin course before? *

Yes

No

If yes, where did you train?

Learning Interests

What other areas are you interested in learning? (Check all that apply)

Advanced botulinum toxin areas

Dermal filler

Combination treatments

Other

Anything else that you are interested in learning more about?

Future Plans

How do you intend to apply the training from the hands-on workshop? (e.g. incorporate into your practice, provide aesthetic treatments in spas near you, just to acquire the knowledge, etc.) *

Do you hope to open your own aesthetic office? *

Yes

No

Additional Information

Anything else that you would like to share?

Any food allergies or restrictions we should know about?

We will be providing snacks, lunch and beverages

Provider Acknowledgement

I confirm that I am a licensed medical provider authorized to perform aesthetic procedures in my jurisdiction. I certify that the information provided in this form is accurate and complete to the best of my knowledge. *

I acknowledge

Provider Signature *

Clear

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