The Aesthetic Foundation In-State Mentor Form

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The Aesthetic Foundation's Externship Program is expanding, and we need your help to provide mentorship to medical students in every state!

Full Name *

Office Address with City & State *

Preferred Phone # *

Email Address *

Please provide a short biography and description of your practice:
*

Please outline what a medical student can expect to learn from a week-long observation of your practice: *

I agree to provide The Aesthetic Foundation with an update after a medical student(s) visits my practice. *

Yes

I will inform my insurance carrier prior to medical student visits to my practice and follow their advice. *

Yes

Are you involved with aesthetic surgery research and interested in mentoring students through the Cooperative Research Externship? *

Yes

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