Surgeon's Application for Enrollment: Liposuction 101 Please Print & Submit this Application by Fax: 949-248-9339
Last Name __________________					First Name _______________			MI__________
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
The American Academy of Dermatology certifies that this educational activity has been recognized for 24 hours of Category I credit for Continuing Medical Education.
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). There is no charge for this course for nurses who attend this course; there is a $500 fee for each registrant which will be refunded after the nurse attends the course. 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 949-369-2594.
Signature of Applicant____________________________________________
For Further Information: Telephone 949-369-2594, Mailing Address: 30280 Ranch Viejo Road, San Juan Capistrano, CA 92675, USA