Exocellure - Clinic Account Registration Form

Clinic Account Registration
Full Name of Clinic Owner*

First NameLast Name
Email Address*
Phone Number
Format: (000) 000-0000.
Clinic Information
Clinic Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Clinic Website (if available)
Clinic Phone Number
Format: (000) 000-0000.
Number of Years in Operation
Number of Staff Members
HydrodermabrasionUltrasound FacialsCryotherapy FacialsDermaplaningOxygen FacialHydraFacialIPL (Intense Pulsed Light)Laser Skin ResurfacingRF MicroneedlingMicroneedlingMicrodermabrasionChemical PeelsOther
Business Registration Information
Business License Number
Tax ID (if applicable)
VAT Number (for international clinics, if applicable)
Shipping & Billing Information
Shipping Address (if different from Business Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Address (if different from Shipping Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Point of Contact
Contact Person Name (if different from the clinic owner)

First NameLast Name
Contact Person Email
Contact Person Phone Number
Format: (000) 000-0000.
Product Interests & Volume
Exo-V Post Procedure ProductExocellure Home Care ProductAll Products
Estimated Monthly Purchase Volume
Terms & Agreements
Business Verification

Upload a copy of your business license or registration document.
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I agree to Exocellure’s Terms & Conditions and confirm that the information provided is accurate.
How did you hear about Exocellure?
Please specify name
Additional Comments or Requests
Should be Empty:

Clinic Account Registration

Clinic Information

Business Registration Information

Shipping & Billing Information

Point of Contact

Product Interests & Volume

Terms & Agreements