MedZen Wizard Step 1 of 4 - Business Information 0% Are you licensed in the states where you are delivering the services? (This program is only available for licensed professionals or companies that hire licensed professionals)* Yes No Choose the state(s) you are licensed to perform services:*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDo you provide every patient an informed consent form that is acknowledged by the patient and is executed for your records?* Yes No (This program is only available for Med Spas that offer proper consent. Unsure about forms? Click Here to Download a Botox/Injectables Patient Consent Form.)Do you have a Medical Director where applicable by the law requirements in your state?* Yes No I am the Medical Director Not required Do you currently or have you ever had an aesthetic related malpractice claim?* Yes No State Complaint and/or Investigation?* Yes No Civil lawsuit for malpractice?* Yes No (If you answer yes to any of the questions above, you will be redirected to schedule a consultation to understand the ability to qualify you for this program) Did you receive certified training for the Botox/Filler/Injectable products and services you are offering?* Yes No How long has your practice been open?* Not open yet <1 year 1 to 2 years 3 to 5 years >5 years Anticipated Opening Date:* MM slash DD slash YYYY Please select your present-day annual revenue for Botox/Filler/Med Spa Injectable Services:* $0 - $50,000 per year $51,000 - $100,000 per year $101,000 - $250,000 per year $250,000 - $1,000,000 per year > $1,000,000 per year Finalize Your QuoteCreate your account to access your own personalized customer portal with Juno. Instantly view your quote, access important files and more!Login Email:* Password:* Enter Password Confirm Password HiddenEmail HiddenName First Last HiddenUntitled HiddenPhoneHiddenPhone HiddenAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code NameThis field is for validation purposes and should be left unchanged.
