Mesotherapy, Lipotherapy, LipoDissolve, Cellulite, Scottsdale, Arizona
Aesthetic MD - Authority on Mesotherapy, LipoTherapy, LipoDissolve, Botox and Whole Body Vibration Exercise

"The Authority in Mesotherapy & Spot Fat Reduction (LipoDissolve / Lipotherapy) for Physician Training and Patient Treatments."
call direct at (602)485-3621

REGISTRATION FORM..

QUESTIONS? (602) 485-3621                    Fax (602) 996-2743

  • Please indicate under title how you want your title listed on your certificate (ie, MD plus any other titles).
  • Registration is not complete until payment is received.
  • Reservations are on a first come basis.
  • AestheticMD reserves the right to refuse admission to any person at its discretion.
Name
Title
Address 1
Address 2
Address 3
City
State/Province
Zip/Postal Code
Country
Primary Telephone
Secondary Phone
FAX
E-mail
Website
Please indicate the seminar or one-on-one training you are attending:
Date DESCRIPTION OF SEMINAR/TRAINING
TUITION TO BE CHARGED TO CREDIT CARD

Credit Card Information - Address is necessary below only card address is if different from address above.

Type of Credit Card

Name as it appears on card
Credit Card Number

Expiration Date

CVV2 - 3 digit number on back of card
Card billing Address
City
State/Province
Zip/Postal Code
Country
Are there any special arraingments we should make for you regarding acessibility needs or dietery needs or any
other speciality information we should know prior to your arrival? (If no, please leave blank)