CPCA Membership Upgrade Application

CPCA Membership Upgrade Application

Annual membership fee for a Full Member or a Fellow is $2,200.00 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

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 FIND-A-DOCTOR section on CPCA's website if your upgrade application is approved. Please make sure that the work contact details are up to date.
Please include http:// or https:// in the website URL

IDENTITY DOCUMENTS

Please upload your Curriculum Vitae (CV).
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
Please upload a photographic copy of passport.
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
Please upload a passport-quality head and shoulders photograph of yourself.
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

APPLICANT'S EXTENSION DETAILS

APPLICANT'S INSURANCE DETAILS

DD slash MM slash YYYY
Please upload the current Certificate of Currency of medical insurance (including the category of procedures of cover, any loadings or restrictions and/or limitations)
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

MEDICAL REGISTRATION

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)
Please upload a copy of AHPRA registration certificate.
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

UNIVERSITY OF GRADUATION

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

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.
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

    MEMBERSHIPS & REFERENCES


    Memberships

    (Please include the telephone number of the entity)
    (Please include the telephone number of the entity)
    (Please include the telephone number of the entity)
    (Please include the telephone number of the entity)
    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.
      Where contact details could not be provided.
      Drop files here or
      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:
         
        Procedure  CURRENT Frequency of Performance  Your Skill and Degree of Competency
         Listed below   Drop down menu to select
         A. I currently perform this procedure OFTEN
         B. I currently perform this procedure OCCASIONALLY
         C. I currently perform this procedure SELDOM
         D. I do not offer this procedure to my patients
         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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        02. Botulinum toxin hyperhidrosis

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        03. Botulinum toxin cosmetic upper face

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        04. Botulinum toxin cosmetic lower face

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        05. Chemical peel - deep dermal

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        06. Chemical peel - medium depth

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        07. Chemical peel - superficial

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        10. Fractional laser resurfacing ablative

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        11. Fractional laser resurfacing non-ablative

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        12. Laser/IPL treatment of vascular lesions

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        13. Laser/IPL treatment of pigmented lesions

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        14. Hair reduction (laser/IPL)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        15. Ablative laser resurfacing (Erbium/CO2)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        16. Laser tattoo removal

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        17. Skin rejuvenation (fractional RF)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        18. Skin rejuvenation (laser/IPL)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        20. Plasma skin rejuvenation (portrait)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        23. HA based fillers - wrinkles and lines

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        25. HA based fillers - deep volume filling

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        26. HA based fillers - Use outside the face

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        27. HA based fillers - skin hydration

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        29. Permanent fillers (e.g. Aquamid)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        30. Rhinoplasty - non-surgical

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        31. Mesotherapy

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        32. Microdermabrasion

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        33. Micro-Sclerotherapy

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        34. Minor excisions and skin biopsies

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        36. Photodynamic Therapy - Acne

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        37. Photodynamic therapy - solar damage/field cancerisation

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

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

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        39. Skin needling (Roll CIT/Dermapen)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        40. Platelet rich plasma treatments

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        41. Small volume fat transfer to face

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        42. Thread lifting under LA

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        Other procedure achieved and performed - #43 (Description)

        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        Other procedure achieved and performed - #44 (Description)


        Write description here and put your grading in the next available field.
        CURRENT Frequency of Performance
        Your Skill and Degree of Competency

        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.
        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 HERE. Thank you.
        Accepted file types: jpg, png, pdf, gif, Max. file size: 5 MB.

        Please ensure that you have answered all the required fields and uploaded all the required documents before clicking the "Submit" button.