Your Registration

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Botulinum Toxin Training	$1,299.00 Discount already applied!
Aug 06 2022 Seattle, WA Renaissance Seattle Hotel

Advanced Botox and Dermal Fillers (Level II)	$1,199.00 Discount already applied!
Feb 06 2022 San Diego, CA The Sheraton San Diego Hotel & Marina

Complete Dermal Filler Training	$1,499.00 Discount already applied!
Dec 10 2022 Los Angeles, CA Hyatt Regency Los Angeles International Airport

Sub-Total: $3,997.00
(-) Discount: $200.00
empty cart Registration: $3,797.00 Credit Card Convenience Fee: $113.91 Total Amount Due: $3,910.91

1 - Customer Information

First Name:

Last Name:

Medical Title:

Email Address:

Telephone:

Are you a Practice Owner?:

State License #:

Name of Account Rep who guided you, if any:

2 - Payment Information

eCheck Payment

Account Type:

Bank (Institution) Name:

Routing Number:

Account Number:

Name on Account:

Amount to be Charged:

Date:

Email for Confirmation:

I (we) understand that this authorization will remain in full force and effect until I (we) notify AAOPM, INC. in writing at the following:

AAOPM, Inc.
2720 East Oakland Park Blvd, #102
Fort Lauderdale, FL 33306
(954) 525-4273
(954) 358-2860 (F)

That I (we) wish to revoke this authorization.

Name(s):

Date:

eSignature: (Please type your full name)

Credit Card Payment
(3% Convenience fee ($113.91))

Card Type:

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CVV:

3 - Billing Information

Address:

Address 2:

City:

Country:

State:

Zipcode:

I acknowledge that I have read and agree with the AAOPM terms of service, privacy policy, and cookie policy. California courses attendees: In order to inject during hands-on sessions, you need to be licensed to inject in California.

Amount to be charged: $3,910.91