Name of Surgery Center or Private Practice *

Your Business Website

Surgeon Full Name

Office Coordinator Full Name

Preferred Email *

(lead) Surgeon/ Owner Instagram Handle

Office Instagram Handle (if different)

Phone *

Company Physical Address (this is where your Precis Hardcopy book will be mailed)

City

State

How Many of your Office Staff are you registering to be Board Certified?

1-10 staff members

11-20 staff members

How many therapist staff members will be providing post surgical lymphatic treatments to clients from Day 1-7?

Names of all staff members in your office that will be Board Certified (Both "THERAPIST" and "ADMIN")

Why do you want your Office/Surgery Center to become Board Certified?

*Note: If surgeons themselves would like to be Board Certified (either as a therapist or an Office staff), they must complete the same process as their staff for either SO iMedic Board Certification option

Your application fee of is due in full now; it will be paid on the the next page. Upon receipt of your application, you will schedule your onboarding call to establish accounts for all of your staff members & enroll them in their respective classes and exams. If you would like your therapists to be certified in offering treatments past Day 7 PostOp, they will also need to apply for their IP Board Certification for their desired Educational Track.

By signing below, I acknowledge that I have read and understood the Standards of Care (SO) Board Certification handbook provided by CSL Therapy Organization. I agree to abide by the policies and guidelines outlined in the certification program. I understand that the application fee for the certification program is nonrefundable. In the event that any therapist in my office fails to pass the Baseline Exam, I understand onsite training will be required to complete their Board Certification. I also agree to participate in the annual Board Certification renewal process to maintain my certification status.