Do you want your Member Profile visible to the public? *

Yes - Please make my Member Profile public

No - Please make my Member Profile private

Name *

First Name

Last Name

License / Certification *

LE

CPE

Are you currently accepting new clients? *

Yes

No

I have a wait list

Would you like to be considered for the "Featured Electrologist" on the homepage? *

The Featured Electrologist will change from time to time, priority will be given to providers that are accepting new clients

Yes

No

Phone Number / Text *

(###)

###

####

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address *

*If different from business address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Modalities *

Galvanic

Thermolysis

Blend

Areas Treated *

ALL

ALL, Other than GRS Prep

Specific Areas Only (Please detail below)

Do you accept insurance? *

Yes

No

Mentorship

Be a Mentor: I am available to mentor new electrologists (via phone, email, etc).

Find a Mentor: I am a newer electrologist that would like to be paired with a mentor.