APPLICANT'S DETAILS Choice of Membership Upgrade (Required) SELECT ONE Full Membership Fellowship Fellowship Equivalence Initiative PRIMARY CONTACT
The College uses the primary contact details for communication to applicants and members. Please make sure that the primary contact details are up to date. WORK CONTACT
The College uses the work contact details in the
section on CPCA's website if your upgrade application is approved. Please make sure that the work contact details are up to date.
IDENTITY DOCUMENTS APPLICANT'S EXTENSION DETAILS APPLICANT'S INSURANCE DETAILS Do you give CPCA permission to check your insurance details, if required? (Required) Select Yes No MEDICAL REGISTRATION Any medical litigation, disciplinary action or investigation by Medical Boards? Select Yes No UNIVERSITY OF GRADUATION FURTHER TRAINING & EDUCATION
Please provide information of further training and education undertaken in the field of cosmetic medicine. If insufficient space, please upload extra page/s in place provided. Training/Education Certificates
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Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB. MEMBERSHIPS & REFERENCES
Memberships Certification of memberships with other colleges, associations & societies, etc.
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB. References
Please provide names and contact details of three (3) referees.
Referees MUST be registered medical practitioners and should ideally be current Fellows of the College.
Wherever possible, you are encouraged to choose cosmetic medical practitioners who have an interest in or a willingness to assist you through mentorship.
Your elected referees must be able to speak for your knowledge and skills, as well as your practical experience within cosmetic medicine. Written References
Where contact details could not be provided.
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Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB. COSMETIC PROCEDURES OR SERVICES CURRENTLY PERFORMED/PROVIDED
Please proceed to the following drop down menus to indicate which cosmetic procedures and services you currently perform, and, on a scale of 1 to 10, to what degree of competency you can perform them.
Please Note: a score of 10 represents at least three years’ active experience in performing the treatment, AND either recent publication(s)/presentations at conferences, or you are a recognised trainer for a supply company for that procedure. Applicants who rate themselves ten more frequently will be scrutinised more closely than those recording an occasional 10 and mostly lower numbers. Please select a number which accurately reflects you experience. Exaggerating ability can lead to rejection of membership or failure to move to higher levels of membership.
As a Guide:
CURRENT Frequency of Performance
Your Skill and Degree of Competency
Drop down menu to select
D. Not in Recent Months
0 = I have never performed this procedure
1 = I have done a few, but I am still feeling my way
5 = I have done several, and my technique is improving
8 = I am completely competent and confident in managing complications
10 = I am a recognised expert in the industry with at least three years of experience and other colleagues seek my advice on performing this treatment.
Applicant's Declaration (Required) 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 08. Fat reduction with energy-based devices- heating and/or cooling based devices 09. 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 treatment/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)
Other procedure achieved and performed - #44 (Description)
Write description here and put your grading in the next available field. OTHER COSMETIC MEDICAL ACHIEVEMENTS AND/OR SERVICES PROVIDED
Please advise the name of the publication, the topic of the article and the date published. Teaching/s
Please provide a short description. Presentations
Please provide a short description. Mentoring
Please provide a short description. Applicant's Declaration
Please provide signed declaration form that can be found
. Thank you.
Please ensure that you have answered all the required fields and uploaded all the required documents before clicking the "Submit" button.