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

Registration: $5,958.00
Total Amount Due: $5,958.00

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:

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

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: $5,958.00


	$5,958.00 remove
1 Exceed™ Microneedling Device 16 Exceed™ Cartridges 1 Neocutis™ HYALIS+ Serum Backbar (200ml) 20 NeoBody Restorative Body Cream (40 ml) 5 Xeomin® 100 unit vials --- ---

remove all discount / vendor code Registration: $5,958.00 Total Amount Due: $5,958.00

Your Registration

1 - Customer Information

2 - Payment Information

eCheck Payment

Credit Card Payment

3 - Billing Information