Apply for Designation Note: Note: The Canadian Board of Aesthetic Medicine reserves the right to reject any practitioner if there is a proof of misrepresentation of the documentation or the files submitted. Note: If you have already completed a CBAM 2 day Certification or 1 day Comprehensive Certification program, please email us at education@cbamedicine.com to process your designation.Select Your Profession: (Based on your profession the fee might change)*Please selectPhysiciansDentistsNaturopathic DoctorsNurse PractitionersNursesRPNsResidents and nursing studentsPhysician assistantMedical AestheticianClinic OwnerTitleDr.Mr.Mrs.Miss.Ms.Prof.Name* First Last Job Title/ Occupation* DesignationMDDORNPhdOtherEmail* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Fax NumberPractice Information:Are you a CBAM member? Yes No Please note the CBAM designations are only awarded to Premium members. You can apply for membership here: https://www.cbamedicine.com/membership-type/What kind of CBAM member are you? Basic Member Premium Member How many years do you have experience working in the field of Aesthetic Medicine? How do you work in aesthetic medicine? I run my own aesthetic clinic/practice I work in an aesthetic clinic What is the name of the clinic you own?* What is the website of your clinic/practice?* What is the name of the clinic/practice where you are working?* What is the website of the clinic/practice where you are working?* Do you practice in any field other than aesthetic medicine?AnesthesiologyDermatologyEmergency MedicineFamily MedicineInternal MedicineCosmetic SurgeryPlastic SurgeryObstetrics/GynecologyOphthalmologyPsychiatryDentistryOtherPlease specify it here which other field do you work? Your name on the certificate / License* Please upload picture of your Medical License, Dentist License, Nursing License, or Naturopathic License here:*Max. file size: 20 MB.What is your licencing body organization?* (for example: Royal College of Physicians and Surgeons of Canada) We might contact this organization to verify your credentials. What is the website of your Licencing body organization?* We might use this website to verify your credentials. Please upload your resume here (if you have one ready)*Max. file size: 20 MB.Please upload here all your certificates in aesthetic medicine: Drop files here or Select files Max. file size: 256 MB. You may upload multiple documents here.* I acknowledge that I have read and agree to the CBAM Terms of Use. CBAM Terms of UseCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
