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First Name *

Last Name *

Practice Name

Email *

Office Phone *

Cell Phone

Address *

Address Line 2

City *

State *

Postal Code *

Medical Specialty *

Full Name of non-clinical staff member

Full Name of Office Manager

Office Manager's Email

Attach Medical License *

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Do you currently practice any method of PRP? *

Yes

No

If yes, what PRP system do you use?

If yes, what procedures do you offer?

If yes, who taught you?

Please select a workshop date with Dr. Lisa Vuich

April 7th, 2019: Facial Artistry Beginner Level- Windham, NH- $2,900

April 27th, 2019: Combination Therapy for Male & Female Sexual Wellness- Windham, NH- $5,495

April 27th, 2019: Combination Therapy for Male & Female Sexual Wellness- Windham, NH (PRP Equipment and Network Membership Included)- $6,995

June 2nd, 2019: Combination Therapy for Male & Female Sexual Wellness- Windham, NH- $5,495

June 2nd, 2019: Combination Therapy for Male & Female Sexual Wellness- Windham, NH (PRP Equipment and Network Membership Included) - $6,995

June 22nd, 2019: Combination Therapy for Male & Female Sexual Wellness- Windham, NH- $5,495

June 22nd, 2019: Combination Therapy for Male & Female Sexual Wellness- Windham, NH (PRP Equipment and Network Membership Included) - $6,995

Add on: One Audit (Non-Clinical Staff Member) - $500

Private Training - $10,000

Please select a workshop date with Dr. Tali Arviv

April 6th, 2019: Combination Therapy for Male & Female Sexual Wellness- Tampa, FL- $5,495

April 6th, 2019: Combination Therapy for Male & Female Sexual Wellness- Tampa, FL (PRP Equipment and Network Membership Included)- $6,995

May 4th, 2019: Combination Therapy for Male & Female Sexual Wellness- Miami, FL- $5,495

May 4th, 2019: Combination Therapy for Male & Female Sexual Wellness- Miami, FL (PRP Equipment and Network Membership Included) - $6,995

Add on: One Audit (Non-Clinical Staff Member) - $500

Private Training - $10,000

How did you hear about SpecialyMEDTraining? *

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Next Workshop April 6th, 2019 • Tampa, FL