Admission Application Form

1Personal Information

Title * Gender * First Name * Last Name * Date of Birth * Nationality * Mobile Number * WhatsApp Number Email Address *

2Address Details

Clinic / Hospital Name Address Line 1 * Address Line 2 City * State * Pin Code * Country

3Academic Qualifications

Primary Medical Degree * Year of Graduation * University / College Name * Postgraduate / Specialisation Degree Year of PG Additional Certifications / Fellowships Medical Registration Number * Registering Council *

4Clinical Experience

Years of Clinical Practice * Current Practice Type * Current Area of Practice / Speciality Prior Exposure to Aesthetic / Laser / Holistic Treatments

5Courses Interested In

Select all that apply.

Any Other Course / Topic of Interest

6Interest in Training Package

Select the package that best suits your learning goals.

7Training Mode & Setup Preference

Select your preferred training format.

Residential ProgrammeHybrid (Online + Clinical)Outreach / At Your Clinic

Preferred Start Date / Month

8Document Uploads

Upload JPG, PNG, or PDF (max 5 MB each). Enable file attachments in the Mail tab.

Passport Photo *

Aadhaar – Front *

Aadhaar – Back *

Medical Degree *

Registration Certificate *

PG / Additional (optional)

9Additional Information

How did you hear about ICLHM? Referral Doctor Name (if any) Learning Goals & Expectations Special requirements / dietary / accessibility

10Declaration & Undertaking

I, the undersigned, hereby declare that the information provided is true; I hold a valid medical degree and registration; I agree to ICLHM rules and fee/refund policy; I consent to academic/promotional use as stated unless I opt out in writing.

I have read and agree to the above declaration and ICLHM Academy's terms and conditions.

Applicant's Name (typed signature) * Date of Application *

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