| Surgeon's Application for Enrollment: Liposuction 101 Please Print & Submit this Application by Fax: 949-248-9339 |
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| Last Name__________________ | First Name _______________ |
MI__________ | |||||||||
| Name you would like to be called (Nickname) ______________________________ | |||||||||||
| Medical Degree (circle one): MD or DO | |||||||||||
| Date of Birth (Needed to check your AMA Profile) mm/dd/yyyy_________________ | |||||||||||
| Street Address ________________________________________________________________ | |||||||||||
| City __________________________ | State/Province ______________ | ZIP___________ | |||||||||
| Telephone (Office) ____________________ | Tel (Home) _____________________ | ||||||||||
| Fax: _______________________________ | E-Mail _________________________ | ||||||||||
| Practice Website (URL) _______________________________________________ | |||||||||||
| Name of your Medical School ______________________________________________________ | |||||||||||
| Current Status (circle one) Resident, Fellow, Faculty, Private-Practice, Other__________________ | |||||||||||
| Type of Practice (circle one) Private, Group, Military, Academic, Other________________________ | |||||||||||
| List your Board Certifications: _____________________________________________________ | |||||||||||
| _____________________________________________________________________________ | |||||||||||
| Have you ever been disciplined by a state licensing board? | No | Yes | |||||||||
| Have you ever had medical malpractice insurance canceled, or limited? | No | Yes | |||||||||
| Have you had chemical abuse or dependency within the past 5 years? | No | Yes | |||||||||
| Size of Surgical Scrubs/Gown (circle one): Extra Small , Small , Medium , Large , X Large , XXL , XXXL | |||||||||||
| Dates of Course for which you are applying? _______________________________________ | |||||||||||
| How did you hear about Liposuction 101? _________________________________________ | |||||||||||
| ___________________________________________________________________________ | |||||||||||
| Required Text: Tumescent Technique: Tumescent Anesthesia & Microcannular Liposuction, by Jeffrey Klein, Mosby, 2000 can be purchased on-line at hksurgical.com or by telephone at 800-909-0060 | |||||||||||
| Refund Policy | |||||||||||
| If notice of cancellation is given 6 weeks (42 days) prior to the course starting date, then the deposit will be refunded minus a $100 handling fee. If notice of cancellation is given less than 6 weeks prior to course starting date, then the entire deposit will be forfeited. However if it is possible to find a replacement student then only $100 will be forfeited. | |||||||||||
| CME Credit | |||||||||||
| Approved for up to 27 hours of CME by University of California, Irvine School of Medicine | |||||||||||
| Concurrent Nursing Tumescent Liposuction Course (Nursing TLC) | |||||||||||
| Concurrent with Liposuction 101 for Surgeons, up to six nurses may take an abbreviated 2-day Nurses' Tumescent Liposuction Course (Nurses' TLC). A deposit of $500 is required to reserve a spot. The deposit will be refunded once the nurse/assistant attends the course (no refund in case of no-shows or last minute cancellations). Surgeons may bring one additional nurse for the Nursing TLC for a fee of $1000. This course is made available on a first-come basis. Telephone for information about Nursing TLC 949-248-1632. | |||||||||||
| Signature of Applicant____________________________________________ | |||||||||||
| For Further Information: Telephone 949-248-1632, Mailing Address: 30280 Rancho Viejo Road, San Juan Capistrano, CA 92675, USA |
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