Join MedResults Network For Free Enroll now with no obligation or long-term commitment! Company Name*Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website Are You The Primary Contact For Your Practice?*YesNoYour Name* First Last Primary Contact Name* First Last Primary Contact Email* Affiliated Physician* Medical Director's Email* How Did You Hear About Us?*Vendor Partner / Vendor Sales RepDirect MailEmailEvent or ConferenceFriend or ColleagueMedResults Network RepresentativeMRN Skin StoreOtherReferring Vendor Partner?*Merz AestheticsEmpire Medical TrainingSientra / BIOCORNEUMSuneva / BellafillHUB InternationalPurchaseClinicCardinal HealthMembers Only ProcessingEVOOtherYour Referring Friend/ColleagueWould you like to opt-into Staples Advantage for discounted pricing on all of your office supplies?**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!YesNoWould you like access to our discounted GPO pricing for your medical/surgical supplies?**Like MedResults, there is no cost for enrollment.YesNoMembers are saving up to 40% on their shipping through FedEx. Do you want to receive this discount on your shipping?YesNoYou 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?YesNoWho is your primary medical supply distributor?*McKesson/PSSHenry ScheinCardinalMedlineMoore MedicalI don't knowPlease indicate any other medical/surgical supply distributors you work with:McKesson/PSSHenry ScheinCardinalMedlineMoore MedicalWhat is your class of trade?*ClinicAmbulatory Surgery CenterSince 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 roomYesNoDo you currently purchase your sutures through your distributor?YesNoI don't knowDo you have an onsite OR (Operating Room)?*YesNoHow many onsite ORs (Operating Rooms) do you have?*12345678910 or moreSelect the following products or services on which you'd like to receive savings (Through our partners in these categories, our members experience the greatest savings). Med Mal Insurance and/or General Liability Group Health Insurance 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) Merchant Processing Patient Financing Medical Education or Training Others MedResults Network Terms & Conditions*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 email@example.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 Create Your Online AccountYour online account is used to access member-only content areas of MedResultsNetwork.com. When logged in, you'll be able to view Vendor Discounts, Contact Vendors, and more.Username*Password* Enter Password Confirm Password Strength indicator CAPTCHANameThis field is for validation purposes and should be left unchanged.