Online Registration is only for new attendees; if you are an existing member please register through Empire's member portal.

$149.00
4th of July Discount Applied

Registration: $149.00
Credit Card Convenience Fee: $4.47
Total Amount Due: $153.47

1 - Customer Information

First Name:

Last Name:

Medical Title:

Email Address:

Telephone:

Are you a Practice Owner?:

Medical State License #:

Name of Account Rep who guided you, if any:

Would you bring your own model?: (if applicable)

Would you like to participate as a model for others?: (if applicable)

2 - Payment Information

eCheck Payment

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
(3.0% Convenience fee ($4.47))

Name on Credit Card:

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. California courses attendees: In order to inject during hands-on sessions, you need to be licensed to inject in California.

Amount to be charged: $153.47


Empire End of the Year Celebration	$149.00 4th of July Discount Applied remove
Dec 07 2019 New York City, NY The Westin New York at Times Square

Clear Cart discount / vendor code codes cannot be combined. Use only one per order. Registration: $149.00 Credit Card Convenience Fee: $4.47 Total Amount Due: $153.47

Your Registration

1 - Customer Information

2 - Payment Information

eCheck Payment

Credit Card Payment(3.0% Convenience fee ($4.47))

3 - Billing Information

Credit Card Payment
(3.0% Convenience fee ($4.47))