Membership Application **Documents needed for application for new members: Fully completed personal details from (application form) Proof of aesthetic or anti-aging trainings attended locally or internationally. Shorten CV Full or Candidate membership will be granted after evaluation and approval of the documents by the academic committee. The committee could ask for more details after evaluation of documents. Membership fee should only be paid after approval of application by the academic committee. Personal Details: Surname* First Name* Title DP Number ID Number* HPCSA Number Email* Postal Code Postal Address Practice Address1* Practice Address2 Telephone Code* Telephone Number* Fax Code Fax Number Special Practice or Procedure Interest(s) Please indicate the procedure that you perform Cosmetic Dentistry Average amount of the procedures per month Peri orbital, maxillofacial areas Average amount of the procedures per month Crowns, Veneers Dermal Fillers Implants Gingival Fillers Tooth Whitening Bruxism Anti-ageing Dentistry Botulinium Toxin Orthodontics Periodontic Contouring Aesthetic or Anti-aging Medicine Tranings or certifications obtained in the previous year: CPD accredited (or CME) Aesthetic or Anti-aging Medicine Tranings attended: Amount of CPD points per event: Any Malpractice/HPCSA cases against you: YES NO If yes, provide details: Membership Fee 2016 ZAR900.00 Cosmetic Dentistry & Facial Aesthetics SocietyABSAAccount number: 408 640 9907Branch: 632 005 Email: [javascript protected email address]
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