Private Training Inquiry

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Please complete this form so I can get to know you and your training needs better.
Requirements for private training:
-Licensed in state of operation
-Must carry malpractice insurance
-Must have current medical director and office space for training
-Must be able to provide all supplies and have them on hand prior to training - list will be sent prior
-For filler- Must have a MINIMUM of 10 vials of Hylenex on hand

PLEASE BE AS THOROUGH AS POSSIBLE WITH ANSWERS

Payments: 50% Deposit due to reserve date, the other 50% due 5 days prior to training day.

Email *

Full name and Title

Please list your license and #

How did you hear about me?

How many days a week do you see aesthetic patients? How many patients do you see per week?

Explain your support at your office. Does your office provide instruction, support, complication management? How available are they to you? If you are a solo provider please state.

Do you have malpractice insurance with cosmetic coverage?

Yes

Clear selection

Please list your medical directors name and license # (NP, PA, RN) or state if you are independent

Is your medical director on site?

Yes

Clear selection

If you are RN, who does your good faith exams and how are they performed? The models for training will need a GFE prior to treatment.

How many years experience do you have with areas you wish to be trained on?

0 years

1-2 years

3 years or more

Clear selection

For laser/IPL training: What device do you have? How old is the device? How many patients have you approximately treated already? Any adverse outcomes? Leave blank if not wanting laser training

Please list what you are interested in being trained on.

Please list other trainings you have received for the areas you are interested in learning, if any.

If you have received trainings for the same areas in the past, what do you think could have been better with those trainings?

What did you like about the previous trainings?

For Fillers or Neurotoxin- Do you have product already purchased and on hand?

Yes

N/A

Clear selection

For Fillers- Do you have hyaluronidase on hand?

Yes

N/A

Clear selection

Where did you purchase or going to purchase your fillers and neurotoxin?

What are your long term goals?

Is there anything else you would like me to know about you?

Please let me know the best way to contact you

Give me some estimated dates you are available for training days.

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