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Coast2Coast featured experts
BECOME A COAST2COAST FEATURED PROFESSIONAL EXPERT

Please take the time to answer the next questions accurately.

First Name

Middle Name or Initial (optional)

Last Name

Name of Facility Where You Practice

Area(s) of Expertise/Specialization

City Where You Practice

State Where You Practice

Zip Code Where You Practice

Website URL

E-mail Contact Address

Telephone Contact Number

Alternate Telephone Contact Number (Optional)




We want our viewers to feel confident that we have made an honest and carefully informed effort to insure the quality of those featured on our website(s). To that end, we are asking you to provide your credentials to support your areas of specialization (i.e. board certification, NCEA certified, licensed esthetician, etc.) Not only do we build credibility by doing a pre-screening, based on the training and credentials of each applicant, but we ultimately safeguard the reputation of each of our Featured Members as well.



FOR PHYSICIANS ONLY

Board Certification (Name of Medical Board)

Medical School Training (Name of University)

Residency Training (Name of Hospital)

Fellowship Training, if Applicable, with Dates

Years Practicing Cosmetic Surgery

Hospital(s) Where You Have Been Granted Privileges

Teaching Positions and Dates of Service, if applicable

Professional Affiliations

If you use a non-hospital based surgical suite, list accrediting organization(s)

Other Credentials You Wish to Share (i.e. awards, published journal articles, professional presentations, etc.)



FOR ESTHETICIANS PRACTICING IN MEDICAL AND DAY SPAS

Are You a Licensed Esthetician? (If so, provide License #)

If NCEA Certified, provide # of Valid NCEA Certificate?

Name of Facility Where You Practice

Street Address Where Facility Is Located

City Where Facility Is Located

State Where Facility Is Located

Zip Code Where Facility Is Located

What Procedures Do You Perform With Particular Skill?

Do You Practice in a Medical Spa or Day Spa?

If Medical Spa, provide specifics of medical supervision provided by a licensed health care provider (i.e. on-site supervision, available by beeper, by phone, by periodic on-stie visits)

If Medical Spa, provide title and name of person who provides on-site supervision



If you offer quality aesthetic services that do NOT fit into a medical or spa category, please provide details of your sevices and credentials, incorporating information from applicable questions listed above.

Details of Sevices and Credentials



INTERVIEW PREPARATION

Desired Interview Topic

Talking Points for Your Interview
(Specific questions you would like to address and answer during your interview)

Talking Point #1

Talking Point #2

Talking Point #3

Talking Point #4

Talking Point #5 - Optional

Talking Point #6 - Optional

Talking Point #7 - Optional

Talking Point #8 - Optional


__________________________________________________________
Kindly sign your name on the line above after you print this form.
TWO FINAL STEPS TO PROCESS YOUR STATUS AS A FEATURED PROFESSIONAL EXPERT

  • Complete your application online and print it out. Then sign it on the line marked "Your Signature" above.
  • Scan your signed application and e-mail it as an attachment to: Email Us
Thank you for taking the time to complete this form. We will contact you shortly about the status of your application.