Advanced Applicant Intake Form | FindMyObservership.com

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Section 1: Personal Information

Full Legal Name * Full name is required.

Email Address * A valid email is required.

WhatsApp / Phone Number * Phone number is required.

Date of Birth * Date of birth is required.

Current Country of Residence * Country of residence is required.

Nationality / Citizenship * Nationality is required.

Gender * Please select your gender.

Address * Address is required.

City * City is required.

State / Province * State is required.

Zip / Postal Code * Zip code is required.

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Section 2: Passport / Identity

Valid passport? * Required.

Passport Expiration Date * Required.

Upload Passport ID Page * Please upload your Passport ID page.

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Section 3: Medical Education

Medical School Name * Required.

Country of Medical School * Required.

Degree Type (e.g. MD, MBBS) * Required.

Graduation Status * Required.

Graduation Year / Expected Year * Required.

Upload Diploma / Enrollment Proof * Please upload your diploma or proof of enrollment.

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Section 4: Professional Background

Current Occupation * Required.

Completed internship / house job? * Required.

Prior clinical experience? * Required.

Prior U.S. clinical experience? * Required.

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Section 5: Exam Status

USMLE Status * Required.

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Section 6: Observership Interest

Observership Type * Please select an observership type.

Preferred Specialty * Required.

Why are you seeking an observership? * Required.

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Section 7: Preferred Start Dates

1st Choice Start Date * Required.

2nd Choice Start Date * Required.

3rd Choice Start Date * Required.

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Section 8: Visa / Invitation Letter

Invitation letters are optional paid add-ons.

Do you require a Visa and/or visa support invitation letter? * Required.

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Section 9: Payment Readiness

Prepared to proceed with the $1000 observership fee if approved? * Required.

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Section 10: Additional Uploads

CV / Resume * CV/Resume is required.

Transcript (optional)

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Section 11: Agreements

★ Required — all must be checked

Submission does not guarantee immediate placement.

Placements depend on availability and scheduling.

Observership fee is $1000 upon approval.

Invitation letters are optional add-ons.

Thank you for applying. Our team will review your application and contact you within 48 hours.

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Section 12: Program Overview

I acknowledge that the Clinical Observership Program is an educational and professional development opportunity at Revival MD Aesthetic Clinic. I understand that participation is a privilege and that I am expected to maintain the highest standards of professionalism, confidentiality, and respect for patients, staff, and the clinical environment at all times. Additionally, I understand that this observership may involve witnessing or assisting with aesthetic procedures, patient consultations, and clinical operations.

★ Required — must be checked

HIPAA & Confidentiality Agreement: I understand and agree that all patient information, clinical records, and proprietary information I encounter during my observership is strictly confidential. I agree to comply with all HIPAA regulations and to never disclose any protected health information (PHI) or clinical data to any unauthorized person. I will not take photographs, videos, or recordings of patients or clinical materials without explicit consent.

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Section 13: Guest Letter of Agreement (if applicable)

If attending as a guest observer, I acknowledge that I am present at the sole discretion of Revival MD Aesthetic Clinic. I accept all terms and conditions stipulated in this agreement, including confidentiality, conduct standards, and program requirements. I understand that my observership may be terminated at any time without notice if I fail to comply with any term herein.

★ Required — must be checked

I have read and agree to the Guest Letter of Agreement terms outlined above.

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Section 14: Liaisons

I understand and agree to the following liaison responsibilities:

★ Required — all must be checked

Maintain a professional demeanor and appearance at all times while on-site.

Communicate respectfully with all staff members, patients, and fellow observers.

Adhere to the assigned schedule and report promptly at the designated times.

Support all clinic efforts and refrain from interfering with clinical operations or patient care.

Refrain from using mobile devices, social media, or personal communication devices during clinical sessions.

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Section 15: Health & Safety Acknowledgment

★ Required — all must be checked

I understand that I will be participating in a clinical program and I voluntarily accept any associated risks, releasing Revival MD Aesthetic Clinic, its owners, physicians, and staff from any liability arising from my participation.

I will follow all health and safety protocols required by Revival MD, including but not limited to use of PPE, sanitation, and infection control procedures.

I am in good health and will notify the clinic immediately if I develop any symptoms of illness during my observership period.

I agree to comply with all workplace safety regulations and will immediately report any unsafe conditions to the appropriate staff member.

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Section 16: Program Fees & Payment Policy

I understand that Revival MD Aesthetic Clinic charges a program fee for the Clinical Observership experience. I acknowledge that all fees are non-refundable once payment has been received and the observership has commenced. I agree that program fees must be paid in full prior to the start of my observership. I understand that Revival MD reserves the right to terminate my participation for any breach of this agreement without refund.

★ Required — must be checked

I have read, understood, and agree to the Program Fees & Payment Policy as described above.

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Section 17: Letter of Recommendation

I understand that a Letter of Recommendation from Revival MD Aesthetic Clinic is provided at the discretion of the clinic's medical director and is contingent upon satisfactory completion of the observership program, adherence to all standards of conduct, and demonstration of professional excellence throughout my participation. A letter is not guaranteed and may be withheld if my conduct or performance is deemed unsatisfactory.

★ Required — must be checked

I acknowledge and understand the Letter of Recommendation Policy.

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Section 18: Program Duration & Minimums

I understand that this observership program has a defined duration and minimum attendance requirements. Failure to complete the minimum hours or days as agreed upon may result in disqualification from receiving a certificate of completion or letter of recommendation.

★ Required — all must be checked

I understand the minimum attendance and duration requirements of the observership program.

I commit to fulfilling the full duration of the program as agreed and will provide advance notice of any schedule conflicts.

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Section 19: Minimum Standards of Behaviour

★ Required — all must be checked

I will adhere to the dress code and personal presentation standards of Revival MD Aesthetic Clinic at all times.

I understand that as an observer I will not perform any clinical procedures unless explicitly authorized and supervised by a licensed medical professional.

I will actively participate in all scheduled learning activities and treat all patients and staff with the highest level of dignity and respect.

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Section 20: Scope of Satisfaction

★ Required — all must be checked

I understand that satisfaction with the observership program is subjective and that Revival MD makes no guarantee regarding the volume or type of procedures I will observe during my program period.

I acknowledge that program fees are non-refundable and that dissatisfaction with the program content does not constitute grounds for a refund.

I understand that Revival MD reserves the right to modify, reschedule, or terminate the observership program at any time, with reasonable notice provided where possible.

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Section 21: Final Agreement Required

By submitting this form, I confirm that I have read, understood, and agree to all terms and conditions set forth in this Clinical Observership Consent & Agreement Form. I acknowledge that this is a legally binding agreement.

★ Required — must be checked

I agree to all terms and conditions of the Revival MD Aesthetic Clinic Clinical Observership Consent & Agreement Form. *

You must agree to the terms to submit.

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Observership Application

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