What is your current degree?*
How did you hear about us?*
What is your professional credentials?*
Who many years have you worked in your professional industry?*

What are your qualifications?*

What size gloves do you wear?*
Glove type?*: Powder free Latex sensitivity

Any food restrictions or allergies?

What type of skin do you have? (check all that apply)
dry sensitive oily acneic

What products are you using?

Have you had the following procedures?
Deep cleansing facial Glycolic or Chemical peel Skin laser resurfacing IPL Laser

Plastic or cosmetic surgery of any kind?
Was it a "positive" experience?

Do you have permanent makeup?

Have you had laser hair removal?

Sclerotherapy: Do you have leg veins? How many?
Are you allergic to lidocaine?

Have you had any of these procedures?
Collagen Cosmoderm/plast Hylauronic Acid

If so, what was the name of Hylauronic acid?
Who administered? M.D. R.N.
How long did your procedure take?
Was it a positive experience?

Have you had Botox injections?
What areas treated? Forehead Corrugator Between the brow Eyes Upper lip Neck
When was the last treatment?
Who administered? M.D. R.N.
How long did your procedure take?

Any other concerns you have to make your experience more comfortable?

Please Choose a Workshop*:

Workshop	Cost	Date (fill in)	Location (fill in)
Sclerotherapy Level I & II	$2000
*Botox for the beginner	$1800
*Juvederm (dermal filler-Allergan)	$1800

*Botox & Juvederm workshop taken together $3200...Save $400.00!

Payment Information:

Credit Card Type*	Visa Mastercard Discover
Name on Card*
Card Number*
Expiration*	(Format: MM/YY)
CCID*	(3-4 digit code usually located on the back of your card)

Hotel information: www.chesterfieldpb.com or www.westpalmbeach.com.
New York City Boutique Hotel TBA.

Fax this registration form (561-651-7216) along with professional license (Md’s, Np’s, Pa’s, Dentist and R.n’s). No aestheticians permitted to participate in the above workshops. You will be contacted within 24 hours to confirm your reservation and speak with Ms. Tozzi regarding workshop(s) you will be attending.

All reservations need to be confirmed with appropriate fees and postmarked 2 weeks prior to workshop.

Thank you for choosing The Art of Beauty for your aesthetic medicine education,

Donna

The art of beauty’s refund policy: Refunds will be given less a $100.00 processing fee if 14 day advance notice is provided. No refunds will be given after that time. Should ‘the art of beauty’ need to cancel an event, the art of beauty will issue a full refund of the registration fee and deepest apology. The art of beauty is ‘NOT’ responsible for monies attendee’s may have spent on nonrefundable or penalty airline tickets or hotel deposits in the event a workshop is canceled or sold out. A minimum number of attendees are required for each workshop. No attendee will be accepted without payment in full.