MedicoreRx Affiliate Area

Affiliate Registration

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Your Name

First

Last

Username

Account Email

Paypal Email

Degree

What type of practitioner are you?

License Number

Website URL

Phone Number

Street Address

Address Line 1

Address Line 2

City

State

Zip Code

How will you promote us?

If you are a medical practitioner, do you consent to being added to our ‘Find a Provider‘ directory?

Yes
No

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Agree to our TERMS OF USE AND PRIVACY POLICY