Provider Registration Form

Become A Provider

Complete form below to join our mission to transform lives with offering the Jesus Shot. Offer inovative solutions to alleviate chronic pain and restore hope for your patients.
With the purchase of the leasing rights to the Jesus Shot Trademark providers receive:
- Lifetime support with our team
- Exclusive access to our secure ordering, with full pharmacy fulfillment
- Trademark rights to the Jesus Shot name, logo and branding
- Ongoing brand protection to safeguard the value of your investment
- Skool membership that will provide training videos and support
Provider Information*

Full NameClinic Name
Phone Number*
E-mail:*
Website*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My Products

Provider Sign UpOne Time Set Up Fee

$2,500.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Become A Provider