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IAFA Application - Medical Professional

Please enter your name as you wish it to appear on your membership certificate

Address and Contact Information

Education and Training

Please indicate Area of Practice: *

Continuing Education and Training

BOTOX and Dermal Fillers Experience

Education Hours in last 3 years *
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Experience in BOTOX and Dermal Filler *

Annual Payment Information

Levels of Accreditation:

Membership: $350

Fellowship: $499

Mastership: $499

Diplomate: $499

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If 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 Aesthetics

121 NE 34th ST Suite 2506A Miami, FL 33137

If paying online by credit card, please continue after submitting this form, you will be directed through the secure credit card payment process.

‚ÄčI 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. *
Terms and Conditions *