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CMA Application for Licensing & Certification

Complete the form below to add a provider to the Cellular Medicine Association. Check the boxes to register for individual licenses.

Check this box if your student was trained in the Vampire® procedures during class. They will be added to the Vampire FaceLift®, Vampire Breast Lift®, and Vampire Facial® directories, membership access will be given, and certificates will be shipped to them. The first 3 months are free.

Check this box if your student was trained in the O-Shot® procedure during class. They will be added to the O-Shot® directory, membership access will be given, and certificates will be shipped to them. The first 3 months are free.

Check this box if your student was trained in the Priapus Shot® procedure during class. They will be added to the Priapus Shot® directory, membership access will be given, and certificates will be shipped to them. The first 3 months are free.

Check this box if your student was trained in only the Vampire Facial® procedure during class (without the Vampire FaceLift® and Vampire Breast Lift®). They will be added to the Vampire Facial® directory, membership access will be given, and certificates will be shipped to them. The first 3 months are free.

Contact Information

All fields in bold are required.

Course Instructor

Workshop Date

Personal Email

Business Email

Company

First Name

Last Name

Medical Credentials Suffix

Website

Office Phone

Cell Phone

Billing Address

Billing Address 2

City

Zip Code

Select Country

Upload Membership Form Here

Credit Card Information

Card Number

CVC

Order Summary

Remember to Check the Boxes to Register for Individual Licenses

Add New Member To The CMA

Contact our team
with any questions:

52 S Section St.
Suite A
Fairhope, AL
36532

Phone:

1-888-920-5311

Email:

support@vampiremarketing.zendesk.com