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 receive your credit card statements.

Country:*

Address:*

Address2:

Office Address

Same as Billing Information

Country:

Address:

Address2:

Shipping Information

Same as Billing Information

First Name:*

Last Name:*

Company:

Country:*

Address:*

Address2:

Select services (check all that you request):
in office ordering: ordering for personal use: online Doctor’s Web Dispensary™:

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).

W-9 download

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.

California Resale Certificate form

Upload California Resale Certificate form:**

DOCTOR AGREEMENT

1) Terms of the Agreement: The term of this Agreement will begin upon our acceptance of your Web Dispensary application and will end when terminated by either party. Either you or we may terminate this Agreement at any time, with or without cause, by giving the other party written notice of termination. You are only eligible to earn fees on sales occurring during the term.
2) Enrollment Process: To begin the enrollment process, Doctor will submit an application to Rejuvenation Science. Rejuvenation Science will evaluate Doctor's application and will notify Doctor of Doctor's acceptance or rejection. Rejuvenation Science may reject Doctor's application if Rejuvenation Science determines that Doctor's site is unsuitable for the Web Dispensary Program. Reasons for rejection can include, but are not limited to the Doctor's inability to provide proof that he or she is a licensed medical professional, Doctor's site promoting violence, discrimination based on race, sex, religion, nationality, disability, sexual orientation, or age, or the Doctor's site promoting illegal activities and/or violating intellectual property rights. 
3) Modification: We may modify any of the terms and conditions contained in this Agreement, at any time and in our sole discretion, by posting a change notice or a new agreement on this site. Modifications may include, for example, changes in the scope of available fee schedules, payment procedures and Program rules. IF ANY MODIFICATION IS UNACCEPTABLE TO YOU, YOUR ONLY RECOURSE IS TO TERMINATE THIS AGREEMENT. YOUR CONTINUED PARTICIPATION IN THE PROGRAM FOLLOWING OUR POSTING OF A CHANGE NOTICE OR NEW AGREEMENT ON OUR SITE WILL CONSTITUTE BINDING ACCEPTANCE OF THE CHANGE.
4) Limitation of Liability: We will not be liable for indirect, special or consequential damages, or any loss of revenue, profits or data, arising in connection with this Agreement or the Program, even if we have been advised of the possibility of such damages. Further, our aggregate liability arising with respect to this Agreement and the Program will not exceed the total fees paid or payable to you under to this Agreement.
5) Independent Investigation: You acknowledge that you have read this agreement and agree to all its terms and conditions. You understand that we may at any time (directly or indirectly) solicit customer referrals on terms that may differ from those contained in this agreement or operate web sites that are similar to or compete with your website. You have independently evaluated the desirability of participating in the program and are not relying on any representation, guarantee or statement other than as set forth in this agreement.
6) SPAM: Rejuvenation Science has a zero tolerance policy for SPAM. Any Doctor accused of SPAMMING will be immediately removed from our Web Dispensary program. The only recourse you will have to maintain your relationship is proof of 'opt in' that will undermine the validity of the Spam complaint. Valid SPAM complaints will result in the immediate termination of your account and forfeiture of any fees owed you.
7) Warranties, Disclaimers: Rejuvenation Science MAKES NO WARRANTIES, EXPRESS, IMPLIED OR OTHERWISE. Rejuvenation Science does NOT guaranty the actual contents of the packages, the effectiveness of the contents, the nutritional claims and statements made on the packaging, or the completeness or accuracy of information on the Rejuvenation Science web site or promotional materials. Refund of price paid or replacement of product is the exclusive remedy agreed to by Rejuvenation Science and Doctor. Rejuvenation Science SHALL NOT BE LIABLE FOR ANY INCIDENTAL OR CONSEQUENTIAL DAMAGES FOR BREACH OF ANY EXPRESS OR IMPLIED WARRANTY ON THESE PRODUCTS. EXCEPT TO THE EXTENT PROHIBITED BY APPLICABLE LAW, Rejuvenation Science DISCLAIMS ANY IMPLIED WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OF THESE PRODUCTS OR ANY PART THEREOF, AND ANY WARRANTY OF NON-INFRINGEMENT OF ANY PATENT, TRADEMARK, COPYRIGHT, OR ANY OTHER INTELLECTUAL PROPERTY RIGHTS. 
Without limiting the foregoing, any warranty to the extent that it is made or deemed made, shall not apply to any Goods which have been subject to your improper storage, maintenance, alteration or other misuse, or to the extent damage or loss results as a consequence of subsequent shipment by you. Your sole remedy, for breach of any warranties or otherwise, is to return the defective Goods to us and our only obligation, upon receipt and inspection of said Goods at our facility, is, at our option, to either replace such non-conforming Goods or to refund or credit the price paid by you for such non-conforming Goods.
The following disclaimer, in substantially similar form, shall accompany any information provided by Rejuvenation Science, including information obtained from the web site www.rejuvenation-science.com, that Doctor provides to their customers.
“The information provided by Rejuvenation Science in any form is general in nature and is intended for use as an educational aid. It does not cover all possible uses, actions, precautions, side effects, or interactions of the products shown, nor is the information intended as medical advice or diagnosis for individual health problems or for making an evaluation as to the risks and benefits of using a particular product. Doctor and their Patient should carefully read all product packaging. If Patient has or suspects that they have a medical problem, Patient should promptly contact their health care provider. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.”
8) Miscellaneous: This Agreement will be governed by the laws of the state of California, home state of Rejuvenation Science. Any action relating to this Agreement must be brought in the federal or state courts located in the home state of Rejuvenation Science, and you irrevocably consent to the jurisdiction of such courts. You may not assign this Agreement, by operation of law or otherwise, without our prior written consent. Subject to that restriction, this Agreement will be binding on, inure to the benefit of and be enforceable against the parties and their respective successors and assigns. Our failure to enforce your strict performance of any provision of this Agreement will not constitute a waiver of our right to subsequently enforce such provision or any other provision of this Agreement.
9) Linking: We will provide you with textual and graphical links (Link Materials) with which you may link your Web site to our Web site. These Link Materials are available in your Web Dispensary login panel in the 'instructions' area. If you are an approved Doctor, we grant you a non-exclusive limited license solely to reproduce and use these Link Materials, including our trademarks to the extent they are incorporated into these Link Materials, only while you are a participating Doctor and only in accordance with the terms and conditions of this Agreement. You many include Link Materials in mailings to your opted-in lists (see section 6 regarding Spam) and in other advertisements at your discretion. You agree to display the Link Materials appropriately on your Web site and in advertisements, and to respect our trademarks, service marks, and other rights in the Link Materials. You will use only these Link Materials to link to Rejuvenation Science, and you will not alter the look or feel of these Link Materials or of our Web site in any way. You will use reasonable efforts to update to new versions of Link Materials as we make them available.
10) Tracking: Rejuvenation Science will be solely responsible for tracking sales using special software that communicates with the assigned discount codes and links. Rejuvenation Science will endeavor to do its best to ensure accurate tracking of orders made by Doctor's patients. ***Affiliates will themselves be solely responsible for ensuring that these special URLs are formatted properly, a necessary prerequisite to accurate tracking of referral sales.*** Notwithstanding the above statement of responsibility by Rejuvenation Science to track sales, Doctors hereby acknowledge and accept that the tracking system employed by Rejuvenation Science is not 100% fail-safe and that there may on occasion be instances of Web Dispensary sales made that are not credited to a Doctor for any of the following possible reasons:
Failure by the Doctor to inform patients to use the assigned Doctor discount code in promotions, webpage links, banner ads, and so on.
Deliberate or accidental actions by customers to circumvent a Doctor's discount code so that our software is unable to accurately track that sale. 
Bugs, glitches or crashes of the tracking software that render it unable to accurately track sales for a period of time.
Acts of nature that cause irretrievable data loss on the computers and back-up disk media.
11) Relationships and Responsibilities: You will be solely responsible for the development, operation, and maintenance of your site and for all materials that appear on your site. For example, you will be solely responsible for:
The technical operation of your site and all related equipment;
The accuracy and appropriateness of materials posted on your site (including, among other things, all product-related materials);
Ensuring that materials posted on your site do not violate or infringe upon the rights of any third party (including, for example, copyrights, trademarks, privacy, or other personal or proprietary rights);
Ensuring that materials posted on your site are not libelous or otherwise illegal.
We disclaim all liability for these matters. Further, you will indemnify and hold us harmless from all claims, damages, and expenses (including, without limitation, attorneys' fees) relating to the development, operation, maintenance, and contents of your site.
12) Permissions: I grant permission for Rejuvenation Science to publish on its website letters and articles submitted by me and to use excerpts in promotional materials. Rejuvenation Science may exercise editorial control over my submissions for the purpose of reducing the chance of breaking FDA and FTC rules and regulations regarding nutritional supplements.
13) Relationship of Parties: Rejuvenation Science and your company are independent contractors, and nothing in this Agreement will create any partnership, joint venture, agency, franchise, sales representative, or employment relationship between the parties. You will have no authority to make or accept any offers or representations on our behalf. You will not make any statement, whether on your site or otherwise, that reasonably would contradict anything in this agreement.

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