Welcome to Rejuvenation Science®!

 Questions? Please call us at
1-888-737-3588 TOLL FREE

Doctor Login

Registered doctors' wholesale ordering, web dispensary tracking, and account management.

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Sign up for Sign up for Practitioner Account

The fields marked * are required.

The fields marked ** are required if you choose the Web Dispensary option and thus we will be remitting funds to you

First Name:*

Last Name:*

Practice name:

Practice specialty:

Email address:*

Office Phone:*

Optional direct contact Phone:

Best time to call:

User name (will be used as doctor discount code):*

Password:*

Confirm Password:*

Billing Address

The mailing address on file with your bank where you would receive your credit card statements.

Country:*

Address:*

Address2:


Office Address

Country:

Address:

Address2:

Shipping Information

First Name:*

Last Name:*

Company:

Country:*

Address:*

Address2:

Select services (check all that you request):
     

Make checks payable to:

Tax ID#:**

Social Security #:**

Your website URL:

You may upload a picture of you, your office, your staff or logo from your computer by clicking the upload button or email a picture to us at info at Rejuvenation-science dot com.

Your Picture:

Please download the W-9 form, complete and sign it, then scan and upload it, or scan and email (info at Rejuvenation-Science dot com) or fax it to us (1-310-798-2830).

Upload completed W-9 form:**

Optional for Practitioners with California offices, please download, complete online, print, sign, then upload, email or fax (1-310-798-2830) the California resale certificate to us. With a completed form on file we do not need to collect California sales tax when we ship to California offices.

Upload California Resale Certificate form:**

DOCTOR AGREEMENT

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* Security Code:

Please write the security code exactly as it is displayed in the image above