Register

Date of Course you are interested in:

Proof of licensure required for Physicians, Physician Assistants, Registered Nurses, Clinical Nurse Specialists and Nurse Practitioners. Letter from training director needed for Fellows in Training. Payment must accompany registration. Space is limited. Register early!

Personal Information

AAAMS ID Number (if applicable):

 MD DO NP RN PA other (specify)

Name (include Titles): [required]

Company/Organization Name:

Office Address:

City:

Zip: [required]

State:

Phone: [required]

Cell Phone:

Fax:

E-mail: [required]


Specialty: [required]

If you are a Physician please enclose a copy of your medical licensure and answer the following questions:

Degrees/Medical School:

Year Graduated:
Postgraduate Specialty Training:


If you are a Health Allied Professional please enclose a copy of your medical licensure and answer the following questions:

Degrees/School:
Year Graduated:


ls this your first AAAMS Conference  Yes No

How did hear about AAAMS?
 Colleague AAAMS Web Fax Mail Google Other

Payment Information

I have enclosed a check in the amount of $

(please make payable to: American Association of Aesthetic Medicine & Surgery)

I hereby authorize the AAAMS to charge the below card In the amount of $

 Master Card Visa Discover American Express

Account number:

Name as it appears on card:

Exp date:

CW2 Code (3-4 digits on the back of the card)

Credit card billing address: (Required)

Cancellation Policy

Cancellation Deadline for Registration: 6 weeks prior to start of course.

Requests received 6 week prior to start of course will receive a full refund less $75.00 administrative fees. Refunds will be processed one month following the close of course.

After the cancellation deadline, all fees paid to AAAMS for the conference registration are nonrefundable

Course are subject to cancellation; AAAMS will refund the registration fees in full, but is not responsible for any travel or accommodation cost or other costs incurred due to such cancellation

Registration confirmation will be e-mailed to you within 1-2 business days

I hererby agree the above terms and conditions and consent to the above charges on my credit card.

NAME: _________________________ DATE: ______________
SIGNATURE:

PLEASE FAX THE ABOVE FORM TO 310-858-4400. THANK YOU.

Hotel Accommodations:

The course will be held at:

Hyatt Regency Century Plaza
2025 Avenue of the Stars, Los Angeles, California 90067, USA
Tel: (1-310) 228 12348 Fax: (1-310) 551 355

You can make a reservation at the Hyatt Regency or the alternative hotel listed below by directly calling the property of your choice.

Crowne Plaza Beverly Hills
1150 South Beverly Drive
Los Angeles, CA 90035
Tel: +1-310-553-6561
Fax: +1-310-277-4469
Email: reservations@cp-beverlyhills.com

If making reservations at the above hotel, please mention “Beverly Hills Aesthetics” in order to receive a special discounted rate.

205656330 Register



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