Apply for Medical Director Support
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Contact Information
Name
First
Last
Title/Position
Medspa/Practice Name
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Practice Details
Type of License Held
Physician Assistant (PA)
Nurse Practitioner (NP)
Licensed Esthetician
Other
Years in Practice
List of Services Currently Offered
Microneedling
Chemical Peels
Laser Treatments
Injectables (e.g., Botox, Fillers)
Other
Please Specify other services:
Medical Director Needs
Which procedures require Medical Director oversight in your practice?
Estimated Number of Procedures Performed Monthly
Preferred Start Date for Medical Director Services
Compliance and Certification
Are all your practitioners properly licensed and certified in the state of Tennessee?
Yes
No
Have you previously worked with a Medical Director?
Yes
No