Registration form

Belkyra Course

Fill out the form below to register for the Intro to Belkyra Course. Once our office reviews your registration form, we will contact you for payment. After 50% non-refundable payment has been received, we will mail your course material. The remaining 50% will be required before your practicum is booked.

Belkyra Course Registration Form

Name

First

Last

Phone #

Mailing Address for Course Material

City

Province

Postal Code

How did you hear about us?

What is your current profession?

Are you practicing injections currently? If yes, where?

Course Cost

I understand that the cost of this course is $1000 + GST. We accept debit, e-transfer, credit card. 50% non-refundable down-payment is due before course material will be shipped.

Please provide proof of your medical licence here.

Maximum file size: 134.22MB

Questions or Comments

Disclaimer: All information is confidential.

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