Name: ______________________________ Date: _____________
Date of birth: ________________________________
Phone number: __________________ Fax number: ___________
E-mail address: __________________________________________
Medical School (Name, city, country, years, degree): ________________________________________________________
Postgraduate Training (Type, school or proctor, dates):
Board Certification: Specialty, year (Attach scan copies):
Years Practicing Cosmetic Surgery: ______________________________
Disciplinary Actions Taken by Any Medical Organization (explain):
LIST THE SPECIALTY IN WHICH YOU WISH TO MAKE THE SPECIALIZATION
(1. Facial Cosmetic Surgery – 1 year; or 2. Body
Contouring Surgery – 1 year; or 3. Cosmetic Medicine – 1 year;
or 4. General Cosmetic Surgery - 3 years = 1. + 2. + 3.) ________________________________________________________
1. Please attach a 2x2 inch photo to the application
2. The one year specialization fee is 17000 Euros.
3. The completed application with fees must be received at least
30 days prior to start of specialization. Incomplete applications
will not be accepted for the upcoming specialization.
4. Attach a list of cosmetic surgery cases prior to specialization,
if any, with patient identification initials or number, surgery
performed, date of surgery, and any postoperative complications
of each patient. Of those include some preoperative photos,
and postoperative photos representing your skills.