Application for Admission Aesthetic Medicine Certificate Program In partnership Admissions Plan of Study Cost of Study Step 1 of 6 | 0% Completed 1. Applicant Identification First Name Middle Initial Last Name Date of Birth Phone Number Email Address Mailing Address Next » 2. Professional Credentials Current Professional RoleSelect a role...APRN Eligibility Warning: This program is specifically designed for Nurse Practitioners (NPs/APRNs). Specialty CertificationUpload Proof of Certification (PDF/JPG) State Licensure Clinical Requirement: Active Florida license required. Upload Copy of License « BackNext » 3. Educational Background Degree TypeSelect...MSNDNPPhDOther Awarding Institution Graduation Date « BackNext » 4. Clinical Experience Years of Clinical Experience Current Practice SettingSelect...HospitalClinicMedspaPrivate PracticeOther Prior Aesthetic Experience NoneBeginnerIntermediateAdvanced « BackNext » 5. Personal Statement & Documents Personal StatementDescribe in a short paragraph your professional goals in aesthetic medicine... AHA Certifications BLS Certification ACLS Certification « BackNext » 6. Compliance & Legal Agreements Malpractice Insurance I have NOT been named in any malpractice claim.I HAVE been named. (Will require extra documentation) Criminal Background I have NOT been convicted of any offense.I HAVE been convicted or pending charges (Will require extra documentation). Acknowledgments I understand this is a 12-week program (Saturdays).I agree to meet clinical readiness requirements.I understand clinical training is at the UM Coral Gables Campus. Legal Compliance Agreements I acknowledge and understand that, if accepted into the Aesthetic Medicine Certificate Program, I will be required to review and agree to the following documents and policies prior to enrollment and participation in any didactic or clinical activities: Student Enrollment AgreementScope of Practice Acknowledgment (Florida-Specific)Clinical Training Liability WaiverMedia Release AuthorizationHIPAA Privacy and Confidentiality Agreement I understand that execution of these agreements is a condition of enrollment and participation in the Aesthetic Medicine Certificate Program. Failure to complete the required acknowledgments and agreements may result in the inability to enroll in the program. I acknowledge that I will be required to review and agree to the above documents and policies as a condition of enrollment. Interview AvailabilityPreferred format...In-personVideo-Conference Final Attestation I certify that all information provided is accurate and complete. I understand that falsification may result in denial of admission or dismissal. E-Signature Date « Back
