Δ Medspa Center InformationPlease provide information about one location only.This field is hidden when viewing the formOwner NameThis field is hidden when viewing the formOwner Email Medspa Name(Required)Website URL Medspa Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Medspa Email Address(Required) Email Address Confirm Email Address MedSpa Phone(Required)Manager InformationManager Name(Required) First Last Manager Email(Required) Manager Cell Phone(Required)This field is hidden when viewing the formParentApplicationIDMedical Director for this LocationSelect or enter a new director...Add New Medical Director Add New If one medical director covers more than one location, you will only have to enter their information once.Medical Director InformationMedical Director Name(Required) First Last Medical Director Email(Required) Medical School (or Nursing School if Nurse Practitioner)(Required)Degree(Required)Primary Practice NameIf the medical director has a primary practice elsewhere, please provide the location. If they practice primarily at this center, enter "this location"Primary Practice PhoneNPI #(Required)License Number(Required)License State(Required) AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Staff InformationHow many service providers work at the location?(Required)Please enter a number from 1 to 1000.Include all medical personnel who provide services, including Doctors, PA's, NP's, Nurses, Aestheticians and any other employees who provide services. Do not include administrative or Front Desk personnel.Service Provider Information(Required)Please list all staff who provide services including physicians, PA's, NP's, Nurses, aestheticians and any other type of provider. Not all RN's have an NPI number. Please enter one if the RN has one. For RN's, aestheticians and other non-medical providers, the NPI field is not required.First NameLast NamePosition/Degree (NP, PA, etc)NPI#License # MDDONDRNNPPAMaster EstheticianEstheticianMedical AssistantOther Add RemoveServices(Required)Please check all services provided at the spa. At least one box must be checked. Neurotoxin injections Dermal Filler injections Biostimulator injections PRP/PRF/PRFM Laser Hair Removal Laser resurfacing Laser (other) RF microneedling RF surface heating IPL/BBL Body Contouring/Body Sculpting Weight Loss Facials (including Hydrafacial, etc) Chemical Peels (medium and/or deep) IV Therapy Lipolysis (Kybella etc) Vaginal Rejuvenation Hair Loss Therapy OtherPlease list any services not on the above listProducts used in Patient Services(Required) Allergan (Botox, Juvederm family of fillers) Galderma (Dysport, Restylane family of fillers, Sculptra) Merz (Xeomin, Radiesse, Belotero) Revance (Daxxify, RHA fillers) Evolus (Jeuveau) Revanesse (Versa Fllers) Hugel (Letybo) Suneva (Bellafill) Other Check each company which supplies products fort medical services. At least one box must be checked.OtherPlease list any other product sourceList main vendors for medical supplies
