Online Registration is only for new customers; if you are an existing member please send an email to info@empiremedicaltraining.com with your request for registrations. If you have any questions please call 866.366.1576.

Total Amount Due: $499.00

1 - Customer Information

First Name:

Last Name:

Medical Title:

Email Address:

Telephone:

Are you a Practice Owner?:

State License #:

Name of Account Rep who guided you, if any:

2 - Payment Information

eCheck Payment

CONSUMER AUTHORIZATION FOR DIRECT DEPOSIT VIA ACH

I (we) hereby authorize EMPIRE MEDICAL TRAINING, INC to electronically debit my account as follows at the depository financial institution named below. I (we) agree that ACH transactions that I (we) authorize comply with all applicable law.

Account Type:

Bank (Institution) Name:

Routing Number:

Account Number:

Name on Account:

Amount to be Charged:

Date:

Email for Confirmation:

I (we) understand that this authorization will remain in full force and effect until I (we) notify EMPIRE MEDICAL TRAINING, INC. in writing at the following:

Empire Medical Training, Inc.
2720 East Oakland Park Blvd, #102
Fort Lauderdale, FL 33306
(954) 525-4273
(954) 358-2860 (F)

That I (we) wish to revoke this authorization.

Name(s):

Date:

eSignature: (Please type your full name)

Credit Card Payment
(2.5% Covenience fee)

Card Type:

Credit Card Number:

Expiration Date:

CVV:

3 - Billing Information

Address:

Address 2:

I acknowledge that I have read and agree with the Empire Medical Training terms of service, privacy policy, and cookie policy.

Amount to be charged: $499.00


Botulinum Toxin Training -	$0.00
Mar 21 2020 Orlando, FL Sheraton Orlando Lake Buena Vista Resort

Complete Dermal Filler Training -	$0.00
Jul 26 2020 Washington, DC Hotel to be announced

Hormone Pellet Training and Therapies -	$0.00
Jul 23 2021 Orlando, FL Hilton Orlando Lake Buena Vista

Complete Dermal Filler Training -	$699.00
Dec 06 2020 Empire-Virtual-Training LiveStream / Online Training

-	$0.00
Jun 01 2021 Empire-Virtual-Training LiveStream / Online Training

Botulinum Toxin Training -	$0.00
Feb 27 2022 New York City, NY Intercontinental NEW YORK Times Square

Advanced Lip Filler Injection Techniques -	$0.00
Oct 15 2023 New York City, NY New York Marriott at the Brooklyn Bridge

Sub-Total: $699.00
(-) Discount: $200.00
remove all discount / vendor code Total Amount Due: $499.00

Your Registration

1 - Customer Information

2 - Payment Information

eCheck Payment

Credit Card Payment(2.5% Covenience fee)

3 - Billing Information

Credit Card Payment
(2.5% Covenience fee)