Register as a Reseller/Dealer:

Use the following form to enter your customer information. Please note that it may take up to two business days to be contacted by our Sales department to create your account.

 

First Name *
Last Name *
Title  
E-mail Address *
     
Company Name *
Company Type  
Tax ID Number  
What is Your Core Business  
If Other, Please Specify  
Esthetician License Number  
     
Address 1  
Address 2  
City  
State  
Zip Code  
Daytime Telephone * - - x
Cell Phone   - -
Fax   - -
     
How did you hear about Dermelect?  
     
Other Products Carried  
Your Website  
     
   
     
   

* Required fields

By submitting your information you hereby acknowledge having Read and Agreed to the Terms and Conditions.

Click here for our terms and conditions.