Practitioner Onboarding Form

Let’s Get You Set Up with Renovatio

We’re excited to welcome you into our practitioner network. Once you complete and submit this form, we’ll enter your information into our system and create your personalized customer portal.

This quick onboarding step helps us verify your credentials and ensures you have full access to our product catalog, exclusive pricing, and ongoing support.

Name and Title/Role

First Name

Last Name

Email

Mobile #

(###)

###

####

Office Phone#

(###)

###

####

Practice Name

Medical License Number and State of Licensure

Practice Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Shipping Address

if different than the physical address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Anything you'd like to share with us?

Questions, notes about your practice, or how we can best support you — we're all ears.

Sales Tax Exemption

Do you have a valid resale or sales tax exemption certificate?

Yes (Please upload your certificate below to qualify for sales tax exemption)

No (No worries — we’ll apply standard sales tax where applicable)

Credit Card on File (Required to Activate Your Account)

To streamline your ordering process, we securely store a credit card on file for future purchases. You will always receive an invoice and confirmation before any charges are processed. Please enter the following details in the box below: Name on Card Card Number Expiration Date CVV Billing Zip Code Prefer to provide your payment details over the phone? Just write “Call me for payment” in the box below, and we’ll contact you after your account is approved. 🔒 All payment details are encrypted and processed through a secure, PCI-compliant system. We never charge without your approval.

Click on the box below

I Authorize Renovatio to use this payment information on any future orders until further notice in writing by me.