THE Aesthetic Academy 2010

REGISTRATION

EARLY REGISTRATION SPECIAL FOR MIAMI
Miami \| November 13, 2010

RSVP Dinner and Educational Workshop
Yes, I plan to attend the Dinner and Educational Workshop.
No, I will not attend.

Please provide the following registration information:

*Indicates a required field

First Name *
Last Name *
Company/Practice Name *
Address *	(Street Address, P.O. Box, etc.)
Address 2	(Suite Number, etc.)
City *
State/Province *
Zip/Postal Code *
Country *
Phone *	Ext. Please include your area code
Fax	Please include your area code
E-mail Address *
Yes, I would like to receive THE Aesthetic Guide as well as any special event announcements via e-mail. To receive THE Aesthetic Guide^®, please tell us either the year or state/providence in which you where born.
State or Year Born
Note: By providing my fax number and/or email address I consent to receive communications sent by or on behalf of Medical Insight, Inc. and its affiliate companies.
Yes, I am interested in receiving information via e-mail from third party industry solution providers. I understand that I can opt-out at any time.
Professional Designation: *
Title: *
Medical Sub-Specialty/Practice: *
Areas of Interest: * (Please check all that apply)
Acne Anti-Aging Body Shaping Cellulite Treatment Dermal Fillers Education and Certification Epilation Implants Leg Veins Medical Imaging Mesotherapy	Networking Events Neuromodulators Pigmented Lesions Practice Management Practice Marketing Skincare Products Skin Rejuvenation Skin Tightening Tattoo Removal Vascular Lesions Other

Refund/Cancellation Policy A refund will be processed minus an administrative fee of $100 if registration is cancelled 30 calendar days prior to event. Otherwise, registrations are non-refundable. Registration fees may be transferred to another individual in lieu of a refund. I have read and understand this refund policy. *