Birmingham Aesthetic Academy Application

Personal Information

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

Residential Address

Street Address City State ZIP Code

Medical Professional Credentials

Professional Title

Current Medical License Number

State/Country of Medical License

License Expiration Date(Required)

Specialty/Field of Practice

Year of Graduation from Medical School

Board Certification 1

Board Certification 2

Medical Experience

Years of Experience in Medical Practice

Have you worked in aesthetic treatments or procedures before?

If yes, please describe your experience

Photo ID Requirement

Please attach a copy of your government-issued photo ID

Max. file size: 50 MB.

Dietary Preferences for Breakfast and Lunch

Dietary Restrictions

Food Allergies

Emergency Contact Information

Emergency Contact Name

Relationship

Emergency Contact Phone

Additional Information

Message

Ready to Get Started?

SCHEDULE YOUR CONSULTATION TODAY!

Are you ready to take the first step toward a more confident you? Contact our office today to schedule a consultation appointment with Board-Certified Cosmetic Surgeon, Dr. Rifai.

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