Ageless Aesthetic Institute, Dr Sharon McQuillan, training and aesthetic consulting

The Ageless Aesthetic Institute
Course Registration Form

* Required

* First Name

**Middle Initial

* Last Name

* Professional Degree

* Address

* City

* State

* Country

* Zip

* Phone

* Fax

* E-Mail

(If you do not have an email please type in "None@thistime.com" ).

* Please Register Me for:
(Check all courses you wish to be enrolled in and then choose location)

Injectables Module

Day 1
Cosmetic Use of Botulinum Toxin A

Day 2
Use of Facial Fillers for Aesthetic Enhancement

Please Select Location:

Columbus, Ohio	Seattle, Washington
October 18-19, 2008 June 6-7, 2008 October 17-18, 2009	July 11-12, 2009
Toronto, Canada	Ft. Lauderdale, FL
March 7-8, 2009 September 12-13, 2009 November 14-15, 2009	February 7-8, 2009

2 day Courses = $4500

Aesthetic Lasers and Light Module

Please Select Location

Columbus, Ohio	Seattle, Washington
October 20, 2008 June 8, 2008 October 19, 2009	July 13, 2009
Toronto, Canada	Ft. Lauderdale, FL
March 9, 2009 September 14, 2009 November 16, 2009	February 9, 2009

1 day Courses = $1500

Aesthetic Treatment Module

Day 1
Sclerotherapy

Day 2
Body Contouring

Day 3
Chemical Peels

Please Select a Location

Columbus, Ohio	Ft. Lauderdale, FL
September 13-15, 2008	January 10-12, 2009 May 16-18, 2009 October 3-5, 2009

1 day Course = $1500

2 day Courses = $3000

3 day Courses = $3500

Payment Terms: 50% due with registration. Balance due 14 days prior to event. An e-mail will be sent as a confirmation of your registration. Refunds will be given (less a $250 processing fee) until 30 days prior to the seminar. After 30 days, no refund will be issued; tuition may be transferred to a future course for an additional fee.

Please provide the information below:

* Credit Card Type:

* Credit Card Number:

example: ( 1234567890123456 )

* Expiration Date:

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What is this?

Referred By:

Accommodations for disabilities: Please notify the CPD office, 12901 Bruce B. Downs Blvd., MDC Box 60, Tampa, FL 33612 or call 813-974-4296 a minimum of ten working days in advance of event if a reasonable accommodation for a disability is needed.

The CPD Office at the University of South Florida College of Medicine reserves the right to cancel this activity due to unforeseen circumstances. In the event of such cancellation, the full enrollment fee will be returned to the registrant. USF will not be responsible for travel expenses incurred by the participant in the unlikely event that the program is cancelled.

Event, activities and facilities of USF are available without regard to race, color, sex, national origin, disability, age, or Vietnam Veteran status as provided by law and in accordance with the University’s respect for personal dignity.

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800.420.2689
614.579.5530

P.O. Box 20642
Columbus, Ohio
43220