Become a Vivant Skincare Professional

Vivant® Pharmaceuticals, LLC, dba Vivant Skincare, allows dermatologists, plastic surgeons, aesthetic nurses, licensed aestheticians, and other licensed medical professionals to act as resellers of Vivant Pharmaceuticals products. To send you information on our products we will need a completed Account Profile Form, copy of your physician’s/aesthetician’s license. A Vivant representative will contact you to provide information on our products and/or to complete your account setup. To finalize your account setup we will additionally need signed Vivant Terms and Conditions and signed Vivant Internet Policies. These measures are designed to protect our valued Vivant customers.

Part I : How did your hear about Vivant

*How did you hear about Vivant? :

If Board Posting or other, please explain :

Who can we thank for referring you (they will receive 10% off their next order)? :

Part II : Primary Licensed Skincare Professional Information

Skincare Professional's Name :

Date of Birth :

Skincare Professional's License Information

State :

Type :

Number :

Exp. Date :

*Are you an independent contractor? :

Are you a business with a Federal Tax ID Number? (If Applicable) :

Business Tax ID No. :

Are you tax exempt? :

Part III : Vivant Account Information

Individual/Business Name :

Individual/Business Owner's Name :

Business Owner Date of Birth :

Billing Address :

Billing Suite or No. :

Billing City :

Billing State :

Billing Zip :

Shipping Address :

Shipping Suite or No. :

Shipping City :

Shipping State :

Shipping Zip :

*Telephone :

Fax :

*Email :

Part IV : Account Profile Information

Which option best describes you :

How many locations do you have? :

How many treatment rooms do you have? :

How many clients do you see per week on average? :

How many skincare professionals do you have performing treatments? :

What type of services do you provide? :

Please list the skincare products/ lines that you currently carry? :