Laser Training Seminar Registration Form - Radiant Aesthetic Solutions

PROFESSIONAL MEDICAL EDUCATION ASSOCIATION, INC. USE THIS PAGE TO ELECTRONICALLY REGISTER FOR SEMINARS.

Credit Card Payments accepted below. Checks are made to Professional Medical Education Assn, and mailed to: PO Box 997, Grove City, OH 43123. You may also Print Out and Complete this form, then mail to the address above or fax to 305-946-0232

Electronic Registration form - all Seminars (use the separate form for Online Training) Once you have registered you will receive an email confirmation within about 24 hours.

Name*

Business*

Where certificate will be mailed.*

Home Address
Work Address

Address where certificate will be mailed.*

Please write your name and credentials EXACTLY as you want them to appear on your certificate. (i.e. Jane Doe, RN, MD, CST, etc.)

Email*

Confirmation, and any course materials will be sent electronically via email to this address, in addition to any course status updates. Watch for emails from "Hightail" in your Spam folder.

Phone*

Must include Area Code & Phone # for US numbers. Use format 5554441212-no spaces, hypens or dots.

Select Training Courses*

Laser Repair Course - 7 days - $6550
3 Day IN Aesthetic Laser - Open Enrollment - $2800
3 Day Ireland Aesthetic Laser - Open Enrollment - $1126
Laser Safety Officer - 2 days MLSO - $895
Laser Techs - 1 Day Medical Laser Safety - $475
Keys Annual Laser Update 3 Day - $195 Alumni, $895 Others

Choose the correct course. If prepaid discounts and/or bonuses are provided, that will be reflected on your invoice or actual credit card change. PLUS-type in the course date & city below for clarification.

Course Date & Location*

List of Dates & Locations

Add a copy of the current ANSI 136.3 Standards? (Provided at course)

Yes

THESE ARE OPTIONAL $155 (American National Standards Institute-Z136.3 Safe Use of Lasers in Health Care Facilities) Only 1 set is required per facility, no per person. Primarily for LSO courses.

Do you plan on taking the NCLC Laser Certification Exam offered at this course? (No additional fee)*

Yes
No

You MUST request the Certification exam either at the time of registration, or no later than one week prior to the course, in order to have an exam available for you to take. NOTE: Call us if you want to take more than one type of exam.

Remarks, Requests, or Discount Code

All discounts will be applied before final processing of your payment.

Payment Method*

Credit Card
Check / Purchase Order

*Enter purchase order # or credit card info

Payment is due prior to the start of the course, and by submission of this registration, I agree to all payment terms of Professional Medical Education Assn which supersedes any terms in our purchase order.

Cardholder Name:

Card Number:

Expiration Date:

3 Digit Security Code on back of card:

If I am paying by credit card, I hereby authorize charges to my card for the item(s) ordered.

By placing this order and clicking the SUBMIT button below, you acknowledge that you have read the Refund Policy and agree with its terms.

Privacy Policy

After you SUBMIT your order, we will follow up within 24 hours after we've processed your registration. All registrations are manually processed by our staff.