Training intake Form Stretch Mark & Scar Revision- Dermaesthetics Wellness MD

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Advanced Paramedical Stretch Mark & Scar Revision Training

Training Intake & Eligibility Form

Thank you for your interest in our medical-led paramedical training program.
Please complete this intake form carefully. Submission does not guarantee acceptance. All applications are reviewed to ensure suitability, scope of practice, and safety standards.

SECTION 1 — APPLICANT INFORMATION

Full Legal Name

Current Place of Practice (Clinic / Business Name)

Email Address

Phone Number

Address

Country

SECTION 2 — PROFESSIONAL BACKGROUND

Primary Profession

Registered Nurse (RN)

Nurse Practitioner (NP)

Medical Doctor (MD)

Licensed Practical Nurse (LPN/RPN)

Paramedical Tattoo Artist

Medical Aesthetician

Cosmetic Tattoo Artist

Other:

Years of Professional Experience

Are you currently insured to perform skin or aesthetic procedures?

Yes

In proces

SECTION 3 — PRIOR TRAINING & EXPERIENCE

Have you completed prior training in any of the following?

Paramedical tattooing

Scar camouflage

Stretch mark revision

Microneedling

Medical aesthetics

None of the above

Briefly describe your experience with scars or stretch mark treatments (if any)

SECTION 4 — TRAINING READINESS

Why do you want to complete this training?

How do you plan to use this training in your practice?

Are you comfortable working on live models under medical supervision?

Are you able to attend the full training format?

Review online theory component - Available 30 days prior to training

2-day in-person training (Oakville, ON)

SECTION 5 — MEDICAL & SAFETY DISCLOSURE

Do you have any medical conditions that could affect your participation (e.g. latex allergy, fainting, skin sensitivities)?

Yes

Clear selection

SECTION 6 — POLICIES & CONSENT

Please review and acknowledge the following:

I understand this is an advanced professional training program

I acknowledge that completion does not grant medical licensure

I agree to practice within my professional scope and local regulations

I understand that results vary and clinical outcomes are not guaranteed

I agree to adhere to infection prevention and safety protocols taught in this course

SECTION 7 — TRAINING DISCLAIMER (CHECKBOX LANGUAGE)

Training Disclaimer & Agreement

I acknowledge that this training is provided for professional educational purposes only. I understand that it does not replace medical education, licensing, or regulatory requirements. I accept full responsibility for ensuring compliance with my local scope of practice, insurance, and health regulations. I release Dermaesthetics Wellness MD, Dr. Daniela Steyn, and Garnel du Preez from liability related to misuse or misapplication of techniques taught.

Yes

SECTION 8 — PAYMENT & NEXT STEPS

How did you hear about this training?

Instagram

Website

Referral

Medical colleague

Other

Additional comments or questions

FINAL CONFIRMATION

Electronic Signature (Full Name)

Date

YYYY

Thank you for submitting your application. Our team will review your intake and contact you within 3–5 business days regarding eligibility and next steps.

Submit

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