On-Site Training Intake Form Personal Information Name * First Name Last Name Phone Number * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Professional Information License/Certification Medical Doctor (MD) Nurse Practitioner (NP) Registered Nurse (RN) Physician Assistant (PA) Other If other, please specify License/Certification Number State/Country of Licensure Business Name Number of Years in Occupation Position/Title Phone Number * (###) ### #### Email * Preferred Method of Contact Phone Email Website http:// Address Address 1 Address 2 City State/Province Zip/Postal Code Country Business Social Media Handles Please provide a brief description of your business/organization Training Goals What type of training course(s) are you interested in? Beginner Cosmetic Injectable Training Advanced Cosmetic Injectable Training Specialty Cosmetic Injectable Training (KYBELLA®, Sculptra®, etc.) Med Spa Business & Services Training Customized Corporate Training Other If other, please specify What are specific topics or areas you would like the training session to cover? Please provide details. How many individuals will be participating in the training session? Please include the number of Providers, Office Staff, and Administration/Management. What is the level of experience of the participants? None Beginner Intermediate Advanced What is your preferred time frame for conducting the training session? 2-Day Training Session 3-Day Training Session What are your preferred dates for conducting the training session? November 9–11 November 16–18 December 7–9 Are there any additional considerations you would like to mention? Are you wanting accreditation credits for this course? Yes No How did you hear about our training services? Word of mouth Online search Social media Email marketing Website Job application Other If other, please specify Would you like to receive information about future training courses or related services? Yes No Declaration * By submitting this intake form, you acknowledge and agree to abide by the terms and conditions set forth by Esthetic Breakthrough Training® for participation in the in-person training sessions. You understand that payment is required in advance to reserve your dates, and refunds will only be provided according to the cancellation policy outlined below. Esthetic Breakthrough Training® reserves the right to cancel or reschedule the training session due to unforeseen circumstances. In such cases, participants will be notified promptly, and alternative arrangements will be offered. By signing this form, you agree to the terms and conditions outlined herein. Thank you!
