Application Information: Liposuction 1A

Application Information: Liposuction 1A

Application Information: Liposuction 1A

Instructions for surgeons:
You may obtain a copy of this application form either by downloading then printing this form, or by contacting us to request that we fax or mail you the form. Contact us by:

Tel: (949) 248-1632 Fax: (949)-248-9339

If you are requesting the reduced attendance fee for Residents, Fellows, and Full Time Faculty please provide a

  • Letter of recommendation, from the chairperson of your academic training program, commenting on your professional ethics and surgical skills.

APPLICATION FORM - LIPOSUCTION 1A

Click here for a printable version of this form

Applicant''s Name
Name of Academic Affiliation (if any):
D.O.B. Month: Day: Year:
Mailing Address: Street
City State/Country Mail Code
Telephone Fax Cell
E-mail
Website URL for Medical Practice
Board Certification(s):
Yes
No
Have you been reprimanded or disciplined by a state medical licensing board?
Yes
No
Have you ever had your professional liability insurance canceled, or limited?
Yes
No
In the past 5 years have you had any chemical dependency or substance abuse?
Please indicate the size of your surgical scrubs/gown/attire.
Extra Small Small Medium
Large Extra Large XXL or XXXL
Home Phone Number:

REFUND POLICY

� If notice of cancellation is given 7 days prior to the course date the deposit will be refunded minus a $100 handling fee.

� If notice of cancellation is given less than 7 days prior to the date of the course starting date then 50% of the entire deposit will be forfeited.

I have read and understand the information on this application form.

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Applicant''s Signature Date

For additional information and dates of scheduled future courses please contact us at:

Telephone: 949-248-1632 Fax: 949-248-9339

Capistrano Surgery Center
30280 Rancho Viejo Road
San Juan Capistrano , CA 92675-1561 , USA

Click here for a printable version of this form

It is suggested that attendees read the book Tumescent Technique, written by Dr. Klein, before arriving in San Juan Capistrano for the course. The book Tumescent Technique may be purchased from HK Surgical, Inc., by telephone at 800-909-0060 or 760-806-6543

Liposuction 1A: $800 ($400 for Residents, Fellows and Full-Time Faculty)
50% of the above fee can be credited toward the $4800 fee for Liposuction 101 .
The American Academy of Dermatology certifies that this educational activity has been recognized for 8 hours of Category I Credit for Continuing Medical Education