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

$500.00
Spring Discount Applied

Total Amount Due: $500.00

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

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

Amount to be charged: $500.00


Blue Diamond Membership - 1 Year Extension	$500.00 Spring Discount Applied remove
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Clear Cart discount / vendor code codes cannot be combined. Use only one per order. Total Amount Due: $500.00

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)