Medical Spa Society | Membership Registration Form

Member Login:	Password:

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Please be thorough and accurate this information will be used for Directory listing.

Professional Designation:
First Name:
Last Name:
Title:
Name of Company:
Street Address:
City:
State:
Zip:
Telephone Number:
Email:
Secondary Email (this will be kept private):
Web Site:
Please Indicate: Application Category Medical Spa	Wellness Center Hospital Day Spa Other:
Member of the Following Association or Society:	International Spa Association Day Spa Association The Spa Association American Academy of Dermatology Other(s):
Specialty:
Facility Hours:
How did you hear about us?	Trade Show Spa Consultant Medical Spa Other:
Accreditation (if any):

Please insert a maximum of 85 words that describes you, your facility or product:


Billing Info	Cost: $300.00
Billing Name
Card Type
Card Number
Card Exp