Online Bookings
 
  * Fields are mandatory
  * Please choose the course that you are applying for below:
     
  Basic
  Advanced
  Other
   
  If other, please specify:
 
   
  Today's date:
  --
   
  Course date:
  --
   
  * Please complete the fields below:
     
  Surname and initials:
  First name:
  ID number:
  HPCSA Reg number:
  Practice number:
  Practice adress:
  Email adress:
  VAT number:
     
  * Postal adress:
   
 
   
  * Please enter the following telephone numbers:
     
  Work/Practice:
  Home:
  Mobile:
     
  * Do you have any specific dietary requirements:
     
  Yes
  No
   
  If yes, please specify:
 
   
  * Please complete the fields below:
     
  In what type of medical/dental practice do you work?
  Are you in partnership /solo practice?
  How many days per month do you spend practicing medical aesthetics?
  What neurotoxin and dermal fillers so you currently use?
     
  * Please list your previous aesthetic courses?:
   
 
   
  Please specify any problem areas /questions that we can focus on.:
   
 
   
  Please upload an image of yourself:
 
   
   
 

Terms and Conditions:

  • No refunds will be paid out for any cancellations 14 days or less to the scheduled training date.

By pressing submit you acknowledge and agree to the following:

  • Full resposnibility for any loss, damage or injury suffered to them or any patients or models attending the scheduled training. Dr Giezing hereby declines any responsibility financially or otherwise in this regard except where such a loss, damage or injury is caused by the trainee or training of the specific training.


 

   
  * I hereby confirm my registration and agree that I have read and understand the terms and conditions as per this registration form :
     
  Yes
   
 
Security Check:   


 
Back Back to top