Application – Medical Spas Info

Entry ID	Street Address	MedSpa Phone	Date Created
Medspa Center Information Δ Medspa Center Information Please provide information about one location only. This field is hidden when viewing the form Owner Name This field is hidden when viewing the form Owner Email Medspa Name(Required) Website URL Medspa Address(Required) Street Address Address Line 2 City State ZIP Code Medspa Email Address(Required) Email Address Confirm Email Address MedSpa Phone(Required) Manager Information Manager Name(Required) First Last Manager Email(Required) Manager Cell Phone(Required) This field is hidden when viewing the form ParentApplicationID Medical Director for this Location 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 Information Medical Director Name(Required) First Last Medical Director Email(Required) Medical School (or Nursing School if Nurse Practitioner)(Required) Degree(Required) Primary Practice Name If the medical director has a primary practice elsewhere, please provide the location. If they practice primarily at this center, enter "this location" Primary Practice Phone NPI #(Required) License Number(Required) License State(Required) State Staff Information How 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 Name Last Name Position/Degree (NP, PA, etc) NPI# License # Services(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 Other Please list any services not on the above list Products 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. Other Please list any other product source List main vendors for medical supplies
Entry ID	Street Address	MedSpa Phone	Date Created