Name *

First Name

Last Name

Phone

(###)

###

####

Do you own the clinic? *

Yes

No

Do you have a Medical Director? *

Yes

No

Will the Medical Director allow me and/or my other certified trainers to inject under them at the training? *

Yes

No

On a scale from 0-10 (0 being no experience & 10 being highly experienced), what is your experience injecting with cannula? *

0

1

2

3

4

5

6

7

8

9

10

Do you have a Merz Account? *

Yes

No

Do you have a Prollenium/Revanesse account? *

YES

NO

Do you have the Derma System from Cellenis? *

YES

NO

You must have malpractice insurance that covers your clinic. Do you have malpractice insurance? *

YES

NO

I acknowledge and authorize Auric Blackwood to charge the remaining training balance to the same card used for my deposit exactly one (1) week prior to my scheduled training date. *

I agree and authorize this charge

I do not agree (I understand this means I cannot proceed with booking my training).