APPLICANT'S DETAILS

Membership Number(Required)

Choice of Membership Upgrade(Required)

Title(Required)

First Name(Required)

Middle Name

Last Name(Required)

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.

Mobile #(Required)

Email Address(Required)

Address Line 1(Required)

Address Line 2

Suburb(Required)

State(Required)

Postcode(Required)

Country(Required)

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.

Company/Organisation/Institution

Address Line 1

Address Line 2

Suburb

State

Postcode

Country

Tel. (Work)

Fax

Email (Work)

Website

Please include http:// or https:// in the website URL

IDENTITY DOCUMENTS

Curriculum Vitae (CV)(Required)

Please upload your Curriculum Vitae (CV).

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

Photographic copy of passport(Required)

Please upload a photographic copy of passport.

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

Passport-quality head and shoulders photograph(Required)

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

Place of Employment or Practice Business Name - #1

Place of Employment or Practice Business Name - #2

APPLICANT'S INSURANCE DETAILS

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

MDO Membership Number(Required)

Cover level/category of practice?(Required)

Cover Expiry Date?(Required)

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?(Required)

Certificate of Currency of medical insurance(Required)

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

Medical Registration No.(Required)

Country of Registration?(Required)

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?

AHPRA registration certificate(Required)

Please upload a copy of AHPRA registration certificate.

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

UNIVERSITY OF GRADUATION

Name of University

Country of University

Year of Graduation

Qualifications Gained

More Information - Other University Qualifications Gained

Evidence of medical and surgical training, or if a student – Confirmation of University Enrolment

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.

Further Training & Education #1

Further Training & Education #2

Further Training & Education #3

Further Training & Education #4

Further Training & Education #5

Training/Education Certificates

Drop files here or

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

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)

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.

Reference #1 - Name & Title(Required)

Reference #1 - Position

Reference #1 - Email Address(Required)

Reference #1 - Telephone Number(Required)

Reference #2 - Name & Title(Required)

Reference #2 - Position

Reference #2 - Email Address(Required)

Reference #2 - Telephone Number(Required)

Reference #3 - Name & Title(Required)

Reference #3 - Position

Reference #3 - Email Address(Required)

Reference #3 - Telephone Number(Required)

Written References

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.

01. Anti-aging treatments: hormones, vitamins

01. Anti-aging treatments: hormones, vitamins (Frequency)

CURRENT Frequency of Performance

01. Anti-aging treatments: hormones, vitamins Score

Your Skill and Degree of Competency

02. Botulinum toxin hyperhidrosis

02. Botulinum toxin hyperhidrosis (Frequency)

CURRENT Frequency of Performance

02. Botulinum toxin hyperhidrosis Score

Your Skill and Degree of Competency

03. Botulinum toxin cosmetic upper face

03. Botulinum toxin cosmetic upper face (Frequency)

CURRENT Frequency of Performance

03. Botulinum toxin cosmetic upper face Score

Your Skill and Degree of Competency

04. Botulinum toxin cosmetic lower face

04. Botulinum toxin cosmetic lower face (Frequency)

CURRENT Frequency of Performance

04. Botulinum toxin cosmetic lower face Score

Your Skill and Degree of Competency

05. Chemical peel - deep dermal

05. Chemical peel - deep dermal (Frequency)

CURRENT Frequency of Performance

05. Chemical peel - deep dermal score

Your Skill and Degree of Competency

06. Chemical peel - medium depth

06. Chemical peel - medium depth (Frequency)

CURRENT Frequency of Performance

06. Chemical peel - medium depth Score

Your Skill and Degree of Competency

07. Chemical peel - superficial

07. Chemical peel - superficial (Frequency)

CURRENT Frequency of Performance

07. Chemical peel - superficial Score

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

10. Fractional laser resurfacing ablative

10. Fractional laser resurfacing ablative (Frequency)

CURRENT Frequency of Performance

10. Fractional laser resurfacing ablative Score

Your Skill and Degree of Competency

11. Fractional laser resurfacing non-ablative

11. Fractional laser resurfacing non-ablative (Frequency)

CURRENT Frequency of Performance

11. Fractional laser resurfacing non-ablative Score

Your Skill and Degree of Competency

12. Laser/IPL treatment of vascular lesions

12. Laser/IPL treatment of vascular lesions (Frequency)

CURRENT Frequency of Performance

12. Laser/IPL treatment of vascular lesions Score

Your Skill and Degree of Competency

13. Laser/IPL treatment of pigmented lesions

13. Laser/IPL treatment of pigmented lesions (Frequency)

CURRENT Frequency of Performance

13. Laser/IPL treatment of pigmented lesions Score

Your Skill and Degree of Competency

14. Hair reduction (laser/IPL)

14. Hair reduction (laser/IPL) (Frequency)

CURRENT Frequency of Performance

14. Hair reduction (laser/IPL) Score

Your Skill and Degree of Competency

15. Ablative laser resurfacing (Erbium/CO2)

15. Ablative laser resurfacing (Erbium/CO2) (Frequency)

CURRENT Frequency of Performance

15. Ablative laser resurfacing (Erbium/CO2) Score

Your Skill and Degree of Competency

16. Laser tattoo removal

16. Laser tattoo removal (Frequency)

CURRENT Frequency of Performance

16. Laser tattoo removal Score

Your Skill and Degree of Competency

17. Skin rejuvenation (fractional RF)

17. Skin rejuvenation (fractional RF) (Frequency)

CURRENT Frequency of Performance

17. Skin rejuvenation (fractional RF) Score

Your Skill and Degree of Competency

18. Skin rejuvenation (laser/IPL)

18. Skin rejuvenation (laser/IPL) (Frequency)

CURRENT Frequency of Performance

18. Skin rejuvenation (laser/IPL) Score

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

20. Plasma skin rejuvenation (portrait)

20. Plasma skin rejuvenation (portrait) (Frequency)

CURRENT Frequency of Performance

20. Plasma skin rejuvenation (portrait) Score

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

23. HA based fillers - wrinkles and lines

23. HA based fillers - wrinkles and lines (Frequency)

CURRENT Frequency of Performance

23. HA based fillers - wrinkles and lines Score

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

25. HA based fillers - deep volume filling

25. HA based fillers - deep volume filling (Frequency)

CURRENT Frequency of Performance

25. HA based fillers - deep volume filling Score

Your Skill and Degree of Competency

26. HA based fillers - Use outside the face

26. HA based fillers - Use outside the face (Frequency)

CURRENT Frequency of Performance

26. HA based fillers - Use outside the face Score

Your Skill and Degree of Competency

27. HA based fillers - skin hydration

27. HA based fillers - skin hydration (Frequency)

CURRENT Frequency of Performance

27. HA based fillers - skin hydration Score

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

29. Permanent fillers (e.g. Aquamid)

29. Permanent fillers (e.g. Aquamid) (Frequency)

CURRENT Frequency of Performance

29. Permanent fillers (e.g. Aquamid) Score

Your Skill and Degree of Competency

30. Rhinoplasty - non-surgical

30. Rhinoplasty - non-surgical (Frequency)

CURRENT Frequency of Performance

30. Rhinoplasty - non-surgical Score

Your Skill and Degree of Competency

31. Mesotherapy

31. Mesotherapy (Frequency)

CURRENT Frequency of Performance

31. Mesotherapy Score

Your Skill and Degree of Competency

32. Microdermabrasion

32. Microdermabrasion (Frequency)

CURRENT Frequency of Performance

32. Microdermabrasion Score

Your Skill and Degree of Competency

33. Micro-Sclerotherapy

33. Micro-Sclerotherapy (Frequency)

CURRENT Frequency of Performance

33. Micro-Sclerotherapy Score

Your Skill and Degree of Competency

34. Minor excisions and skin biopsies

34. Minor excisions and skin biopsies (Frequency)

CURRENT Frequency of Performance

34. Minor excisions and skin biopsies Score

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

36. Photodynamic Therapy - Acne

36. Photodynamic Therapy - Acne (Frequency)

CURRENT Frequency of Performance

36. Photodynamic Therapy - Acne Score

Your Skill and Degree of Competency

37. Photodynamic therapy - solar damage/field cancerisation

37. Photodynamic therapy - solar damage/field cancerisation (Frequency)

CURRENT Frequency of Performance

37. Photodynamic therapy - solar damage/field cancerisation Score

Your Skill and Degree of Competency

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

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

CURRENT Frequency of Performance

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

Your Skill and Degree of Competency

39. Skin needling (Roll CIT/Dermapen)

39. Skin needling (Roll CIT/Dermapen) (Frequency)

CURRENT Frequency of Performance

39. Skin needling (Roll CIT/Dermapen) Score

Your Skill and Degree of Competency

40. Platelet rich plasma treatments

40. Platelet rich plasma treatments (Frequency)

CURRENT Frequency of Performance

40. Platelet rich plasma treatments Score

Your Skill and Degree of Competency

41. Small volume fat transfer to face

41. Small volume fat transfer to face (Frequency)

CURRENT Frequency of Performance

41. Small volume fat transfer to face Score

Your Skill and Degree of Competency

42. Thread lifting under LA

42. Thread lifting under LA (Frequency)

CURRENT Frequency of Performance

42. Thread lifting under LA Score

Your Skill and Degree of Competency

Other procedure achieved and performed - #43 (Description)

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

43. Other procedure achieved and performed (Frequency)

CURRENT Frequency of Performance

43. Other procedure achieved and performed Score

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.

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

44. Other procedure achieved and performed (Frequency)

CURRENT Frequency of Performance

44. Other procedure achieved and performed Score

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.

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. Thank you.

Upload Applicant's Declaration(Required)

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.

CPCA Membership Upgrade Application

CPCA Membership Upgrade Application

APPLICANT'S DETAILS

PRIMARY CONTACT

WORK CONTACT

IDENTITY DOCUMENTS

APPLICANT'S EXTENSION DETAILS

APPLICANT'S INSURANCE DETAILS

MEDICAL REGISTRATION

UNIVERSITY OF GRADUATION

FURTHER TRAINING & EDUCATION

MEMBERSHIPS & REFERENCES

Memberships

References

COSMETIC PROCEDURES OR SERVICES CURRENTLY PERFORMED/PROVIDED

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)

OTHER COSMETIC MEDICAL ACHIEVEMENTS AND/OR SERVICES PROVIDED

Publications

Teaching/s

Presentations

Mentoring

Applicant's Declaration

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