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Fill in our retailer form below and submit. We'll get back to you as soon as we've reviewed your information.

General Information

General Information

Business Name *

Business Owner Name *

EIN Number *

Street Address *

City *

State *

Zip *

Country *

Office Phone *

Office Email *

Business Website *

Instagram Business URL/Social Media Handle *

Number of Years in Business *

1-3 years
4-9 years
10-25 years

Tell Us More About Yourself

Business and Service Information

How would you describe your company? *

Medical Spa
Dermatology
Plastic surgery
General practice
Health & wellness
Other

If other, please specify: *

How did you hear about RajaniMD? *

Are you currently working with a RajanMD representative? *

Yes
No

If so, what is their name?

Does your company provide PRF procedures? *

Yes
No

Do you currently have a store front or online store? *

Yes
No

What other skincare lines do you offer? *

What products do you currently carry for your clients?

Current sales volume?

$0 - $10,000
$10,000 - $100,000
$100,000 - $1 million
$1 million +

Do you currently carry supplements? *

Yes
No

Do you have a medical director?

Yes
No

What are your goals for your practice?and how can RajaniMD help you fulfill them? *

Your Name *

Title

Signature *

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon to discuss your application!

Make it an amazing day!

The RajaniMD Team

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon to discuss your application!

Make it an amazing day!

The RajaniMD Team

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