AAI Instructional Course Models

Please fill out the model information sheet below. Note the areas on your face you would like to be corrected and the US Cities that are closest for you to travel to. There is a $100 fee for each syringe of dermal filler product used. There is a flat fee of $100 for the BTX-A injections. By filling out this sheet, you are volunteering to be an AAI model at an upcoming injectable training course. Filling out this model information sheet does not mean you will be called, but it does put you on a list of models for your geographic area. AAI course attendees typically bring their own patients for injecting at training courses. You will be contacted only if you are needed as a model. Thank you for your volunteerism and aesthetic interest.

PATIENT INFORMATION/MEDICAL HISTORY
Name*
Email*
Date
Age*
Address
Street
City State Zip Code
Phone
Home Work Cell
Date of Birth* Marital Status Employer Occupation Emergency Contact Relationship Phone Home Work Cell Health History Medication (prescription and over the counter; vitamins, herbal medications) Allergies Surgeries/Dates Have a History of? Heart Disease Mental Disease (Psychological Disorder/Diagnosis) Neuro-muscular Disease Excessive Bleeding Auto-immune Disorders Diabetes High Blood Pressure Liver Disease Cold Sores/Fever Blisters Other     Are you? Pregnant Nursing Do you? Smoke Drink Alcohol Amount per day What areas are you interested in having corrected? What products are you interested in? What products have you ever been injected with and in what areas? What Cities are near you within driving distance? The above information is true and accurate to the best of my knowledge. (Electronic signature) Patient Signature Date       Please wait...