Home > Dental PractitionerIAFA Application - Dental Practitioner Download the Application Form Please enter your name as you wish it to appear on your membership certificate First Name* Middle Name Last Name* Degree(s) Address and Contact Information Practice/Business Name * Line 1* Line 2 City* State* Zip Code* Country* Office Telephone * Office Fax Cell Phone Office Website Address Email 1 * Choose One * Choose One*WorkPersonal Email 2 Choose One Choose OneWorkPersonal Best Time to Contact: * Preferred Method of Contact? * Preferred Method of Contact? *Work EmailPersonal EmailWork PhoneCell Phone Education and Training Undergraduate School * Degree(s) * Year * Medical School Degree(s) Year Specialty or Post-Graduate Studies Degree(s) Year Please indicate Area of Practice: * Please indicate Area of Practice: * General Practitioner Periodontist Endodontist Oral & Maxillofacial Surgeon Prosthodontist Implantology OrthodontistContinuing Education and Training Course Name * Number of Credit Hours * Year * Course Name Number of Credit Hours Year Course Name Number of Credit Hours YearBOTOX and Dermal Fillers Experience Education Hours in last 3 years * Education Hours in last 3 years * Choose Below * Choose Below * Level 1 Training Level 2 Training Experience in BOTOX and Dermal Filler * Experience in BOTOX and Dermal Filler * Less than 10 cases 10-49 cases 50-100 cases +100 casesAnnual Payment InformationLevels of Accreditation:Membership: $350Fellowship: $499Mastership: $499Diplomate: $499 Choose Payment Type * Choose Payment Type * Check Credit CardIf paying by check, please make payable to INTERNATIONAL ACADEMY OF FACIAL AESTHETICS and mail to the address below. Your application will be complete once we receive both your form and check payment. International Academy of Facial Aesthetics121 NE 34th ST Suite 2506A Miami, FL 33137If paying online by credit card, please continue after submitting this form, you will be directed through the secure credit card payment process.I understand that I have the option to print this form, sign, and fax to (305) 938-5018. By submitting online, I am authorizing the Internatioonal Academy of Facial Aesthetics to process my application for the selected Levels of Accreditations. If paying by credit card, I understand that membership will be renewed every 12 months from the date of joining and automatically charged to my credit card on file. I understand that I can call to cancel at any time and a prorated refund will be offered. Please type in your full name to act as your signature in full agreement with these terms and conditions. * Please type in your full name to act as your signature in full agreement with these terms and conditions. * Terms and Conditions * By checking this box, I am signifying that I have read and understand these terms and conditions. Submit IAFA Application Medical Professional Dental Practioner Events 2019 Schedule of Events 2019 Symposium Sponsor Deck Event Registration 2019 IAFA Meeting 2018 IAFA Meeting
