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Are You The Primary Contact For Your Practice?
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Your Name
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Medical Director Name
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First
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How Did You Hear About Us?
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Vendor Partner / Vendor Sales Rep
Direct Mail
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Event or Conference
Friend or Colleague
MedResults Network Representative
MRN Skin Store
Other
If referred by "Other", please help us to be more specific.
Empire Medical Training Event
Live Conference / Industry Seminar
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Referring Vendor Partner?
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Merz Aesthetics
Empire Medical Training
Sientra / BIOCORNEUM
Suneva / Bellafill
HUB International
PurchaseClinic
Cardinal Health
Members Only Processing
EVO
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Your Referring Friend/Colleague
Would you like to opt-into Staples Advantage for discounted pricing on all of your office supplies?
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*If you select yes, you'll have access to complete the creation of your Staples Advantage account below. This will provide you access to the Staples Advantage site where you can purchase discounted office supplies at no additional cost to you. Through your membership, you'll also have access to free overnight shipping and added discounts and cash back on many of your Staples purchases!
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No
Would you like access to our discounted GPO pricing for your medical/surgical supplies?
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*Like MedResults, there is no cost for enrollment.
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No
Members are saving up to 40% on their shipping through FedEx. Do you want to receive this discount on your shipping?
Yes
No
You and your employees can utilize our partner's Enterprise, National and Alamo rental car contracts for savings on Business and Leisure travel. Are you interested?
Yes
No
Who is your primary medical supply distributor?
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McKesson/PSS
Henry Schein
Cardinal
Medline
Moore Medical
I don't know
Please indicate any other medical/surgical supply distributors you work with:
McKesson/PSS
Henry Schein
Cardinal
Medline
Moore Medical
What is your class of trade?
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Clinic
Ambulatory Surgery Center
Since you chose "Ambulatory Surgery Center" as your class of trade, let us know if this sounds like you:
Many suppliers only recognize Surgery Centers if they meet the following requirements. * Have a sterile Operating Room * Use general anesthesia * Have a recovery room
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No
Do you currently purchase your sutures through your distributor?
Yes
No
I don't know
Do you have an onsite OR (Operating Room)?
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Yes
No
How many onsite ORs (Operating Rooms) do you have?
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1
2
3
4
5
6
7
8
9
10 or more
Select the following products or services on which you would like to receive savings (Through our partners in these categories, our members experience the greatest savings).
Select All
Med Mal Insurance and/or General Liability
Medical Supplies (In-Office)
Medical/Surgical Supplies (For Practices With Onsite ORs)
Injectable Fillers (Belotero or Radiesse)
Injectable Filler (Bellafill)
Medical-Grade Skincare (SkinMedica or Others)
Facial Rejuvenation Devices
Compounded Medications
PDO Threads
Merchant Processing
Patient Financing
Medical Education or Training
Marketing Services & Applications
EMR / EHR Software
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MedResults Network Terms & Conditions
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To confirm, MedResults Network is a buying network of aesthetic physicians and medical spas. Your membership is entirely free. There is no obligation to purchase and no change in the way that you purchase or pay for products and/or services. You may opt out of membership at any time. Simply advise the participating vendors that you are a member. Vendor and/or client references available on request. Any MedResults Network member participating in the MedResults Network rebate program will not seek federal, state, or local healthcare reimbursement (e.g. Medicare, Medicaid, VA or otherwise) for any products for which it receives a rebate nor may any of the Merz products be resold other than to a client or patient. For questions, comments, or suggestions contact MedResults Network at info@medresultsnetwork.com Attn: Jamie Parrott or call (844) 799-2384. To fax this form to MedResults Network, please dial (562) 391-4407.
I Agree to the Terms & Conditions
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