AesthetiMatch Form: In search of a Nurse Injector Registration
Please fill in your details.
First name
Last name
What is your medical specialization? (ex: Cardiologist, Family Med, Psychiatrist, etc.)
Which state(s) are you licensed to practice in?
ALL
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Phone Number
Email
Address
Job Title
Do you have a Compact license?
Yes
No
Background: Do you currently have malpractice or professional liability insurance to cover you as a collaborating physician or medical director?
Yes
No
Other
Background: Have your privileges ever been abridged or suspended?
Yes
No
Other
Background: Have civil or administrative charges ever been filed against you?
Yes
No
Other
Background: Have you ever plead guilty, been found guilty, or plead no lo contendere for controlled substances?
Yes
No
Other
Background: Have you ever been denied malpractice insurance after your application?
Yes
No
Other
Background: Are you currently, or have you ever been enrolled in a PHMP program?
Yes
No
Other
Background: Are you willing to submit to a background check?
Yes
No
Other
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