Exocellure - Clinic Account Registration Form

Clinic Account Registration
Full Name of Clinic Owner*

First NameLast Name
Email Address*
Phone Number
Clinic Information
Clinic Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Clinic Website (if available)
Clinic Phone Number
Number of Years in Operation
Number of Staff Members
Primary Services Offered

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
Product Interests & Volume
Select the products you're interested in:

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