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Nurses & Medical Assistants Training Application
Please Print & Submit this Application by Fax: 949-248-9339
Refund Policy
If notice of cancellation is given 3 weeks 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 3 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.
Cancelation of Course
In the event course is canceled, the tuition fee will be refunded.
CEU Credit
The California Board of Nursing certifies that this educational activity has been recognized for up to 24 hours of credit for Continuing Education Units.
Concurrent Nursing Courses
Concurrent Nursing Tumescent Liposuction Course – "Nursing TLC" (space limited to 6 participants). Fees for the Nursing TLC ($2,500) will be waived if the nurse is attending the course with a surgeon, with the exception of a $500 deposit, which will be refunded upon successful completion of the course by the nurse. Surgeons may bring one additional nurse for a reduced fee of $1,000 (pending availability). This course is made available on a first-come/first-serve basis.
Name
First
Last
Name you would like to be called (nickname):
Degree (choose one):
PA
NP
RN
Birth Date (For AMA profile):
MM
/
DD
/
YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
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Nauru
New Zealand
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Papua New Guinea
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Tonga
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Algeria
Angola
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Republic of the Congo
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Togo
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Country / Region
Phone
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Email
Have you ever been disciplined by a state licensing board?
Yes
No
Have you ever had medical malpractice insurance canceled, or limited?
Yes
No
Have you had chemical abuse or dependency within the past 5 years?
Yes
No
Size of Surgical Scrubs:
Please select
XS
S
MED
L
XL
XXL
XXL
Date of Course for which you are applying?
MM
/
DD
/
YYYY
How did you hear about Liposuction 101?
Today's Date:
MM
/
DD
/
YYYY
Signature
*
Typing your full name in this box acts as your electronic signature