2022 Upgrade to Full Membership

2022 Upgrade to Full Membership - Application Form

Annual membership fee for a Full Member is $2200 including GST, or part there of (pro-rata). Please ensure ALL your details are complete and up to date in the Member Profile Area of the Member CPCA Website before proceeding. For assistance or further information, please feel free to contact us via email to membership@cpca.net.au or telephone Julie 0407 788 587. Thank you.

APPLICANT'S DETAILS

Membership Number

Title*

First Name*

Last Name*

Mobile #*

Email Address*

MEMBER'S INSURANCE DETAILS

Which medical defence organisation (MDO) are you covered by?*

MDO Membership Number*

Cover level/category of practice?*

Cover Expiry Date?*

Do you have any additional procedures added to your policy? (Please provide details)

Do you give CPCA permission to check your insurance details, if required?*

Select

MEDICAL REGISTRATION

Medical registration number?*

Country of Registration?*

Please list any restrictions or conditions imposed

Please be specific. Indicate which body/organisation (e.g. TGA/HCCC/etc) imposed the restrictions or conditions and which are current, which are prior. Please include those that were dismissed or deemed not necessary to appear on any registers, etc. (max. 3 lines)

Any medical litigation, disciplinary action or investigation by Medical Boards?

Select or enter value

UNIVERSITY OF GRADUATION

Name of University

Country of University

Year of Graduation

Qualifications Gained

More Information - Other University Qualifications Gained

FURTHER TRAINING & EDUCATION

Please provide information of further training and education undertaken in the field of cosmetic medicine since joining the College. If insufficient space, please upload extra page/s in place provided.

Further Training & Education #1

Further Training & Education #2

Further Training & Education #3

Further Training & Education #4

Further Training & Education #5

MEMBERSHIPS & REFERENCES

Memberships:

Industry association/society membership - #1

(Please include the telephone number of the entity)

Industry association/society membership - #2

(Please include the telephone number of the entity)

Industry association/society membership #3

(Please include the telephone number of the entity)

Industry association/society membership #4

(Please include the telephone number of the entity)

References

Please provide the details of three cosmetic medical practitioners who will be happy to provide a reference for you.

Cosmetic Medical Practitioner, Reference #1

(please provide persons title, name, position, telephone number and email address)

Cosmetic Medical Practitioner, Reference #2

(please provide persons title, name, position, telephone number and email address)

Cosmetic Medical Practitioner, Reference #3

(please provide persons title, name, position, telephone number and email address)

COSMETIC PROCEDURES OR SERVICES CURRENTLY PERFORMED/PROVIDED

Please proceed to the following table to indicate which cosmetic procedures and services you currently perform and to what degree of competency.

On a scale of 1 to 10:

With 10 being at least 3 years active experience in performing the treatment and having presented papers at conferences on the subject (and/or you are a recognised trainer for a supply company for the procedure), and 1 being new to this procedure, please mark accordingly.

As a guide:

0 = Not performed.

1 = Do a few, still feeling my way.

4 = Do several with my technique improving.

8 = Perform solidly, competently, confidently and able to manage complications.

10 = Perform expertly and recognised as an expert in the profession. Hold at least 3 years of experience and other colleagues seek my advice on how to perform this treatment..

Applicant's Declaration*

I have read these instructions on how to complete the following self-rating table. I understand I am to provide a honest self-evaluation of the treatments and procedures that I am currently providing to my patients and not for treatments and procedures that I have performed in the past and no longer offer to my patients.

01. Anti-aging treatments: hormones, vitamins

02. Botulinum toxin hyperhidrosis

03. Botulinum toxin cosmetic upper face

04. Botulinum toxin cosmetic lower face

05. Chemical peel - deep dermal

06. Chemical peel - medium depth

07. Chemical peel - superficial

8. Fat reduction with energy-based devices- heating and/or cooling based devices

9. Fat reduction - Lipo-dissolving treatments (Injection Lipolysis)

10. Fractional laser resurfacing ablative

11. Fractional laser resurfacing non-ablative

12. Laser/IPL treatment of vascular lesions

13. Laser/IPL treatment of pigmented lesions

14. Hair reduction (laser/IPL)

15. Ablative laser resurfacing (Erbium/CO2)

16. Laser tattoo removal

17. Skin rejuvenation (fractional RF)

18. Skin rejuvenation (laser/IPL)

19. Skin tightening - Monopolar RF (e.g. Thermage, Ultherapy & Titan)

20. Plasma skin rejuvenation (portrait)

21. Plasma pen devices e.g. Plexr, ACCOR treatments, e.g. for eyelid reduction

22. HA based fillers - augmentation of folds, e.g. NL's

23. HA based fillers - wrinkles and lines

24. HA based fillers - fine contouring, e.g. around and under the eyes

25. HA based fillers - deep volume filling

26. HA based fillers - Use outside the face

27. HA based fillers - skin hydration

28. Biostimulating injections (e.g. Radiesse, Ellanse & Sculptra)

29. Permanent fillers (e.g. Aquamid)

30. Rhinoplasty - non-surgical

31. Mesotherapy

32. Microdermabrasion

33. Micro-Sclerotherapy

34. Minor excisions and skin biopsies

35. Use of energy-based devices for tretment/removal of raised lesions such as moles

36. Photodynamic Therapy - Acne

37. Photodynamic therapy - solar damage/field cancerisation

38. Phototherapy using red or blue non-coherent light for acne, anti-inflammation

39. Skin needling (Roll CIT/Dermapen)

40. Platelet rich plasma treatments

41. Small volume fat transfer to face

42. Thread lifting under LA

Other procedure achieved and performed - #43 (Description)

Write description here and put your grading in the next available field.

Other procedure achieved and performed - #43 (Score)

Other procedure achieved and performed - #44 (Description)

Write description here and put your grading in the next available field.

Other procedure achieved and performed - #44 (Score)

OTHER COSMETIC MEDICAL ACHIEVEMENTS AND/OR SERVICES PROVIDED

Publications:

Please advise the name of the publication, the topic of the article and the date published.

Publication #1

Publication #2

Publication #3

Teaching/s:

Please provide a short description.

Teaching #1

Teaching #2

Teaching #3

Presentations:

Please provide a short description.

Presentation #1

Presentation #2

Presentation #3

Mentoring:

Please provide a short description.

Mentoring #1

Mentoring #2

Mentoring #3

Applicant's Declaration

Please provide signed declaration form that can be found here: https://cpca.net.au/wp-content/uploads/2021/10/20211012-Applicants-Declaration-1.pdf Thank you.

FILE MANAGEMENT

Please provide the following support documentation via the upload feature below: (combined files must not exceed 5Mb) (formats suitable: PDF, JPG, JPEG, MSWord).

Tick - CV Uploaded*

Tick - Head & Shoulders Photo Uploaded

Tick - Copy of Passport Uploaded

Tick - Training/Education Certificates Uploaded

Tick - Membership Certificates Uploaded

Related to industry associations and societies.

Tick - Medical Registration Certificate*

Tick - Copy of Medical Indemnity Fund Membership - showing level of cover*

Details maybe checked to ensure that all our members have adequate cover.

Tick - Written References Uploaded

Where contact details could not be provided.

Tick - My signed Applicant's Declaration has been uploaded*

File Attachments

Drag and drop files here or

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