Practitioner/Owner First Name *

Practitioner/Owner Last Name *

Email *

Phone Number

Shipping Address *

Practitioner Specialty *

Copy of Practitioners License:

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Acknowledgement:

I understand that in order to carry the IMT Wellness brand, I am required to hold a current, active, and non-restricted license to practice, and that IMT Wellness has a right to request proof of licensure at any time while I’m carrying the products.

I agree to abide by IMT Wellness’ policy on internet sales, in that in no event shall I sell any IMT Wellness products through any third-party seller, such as Amazon or eBay.

By entering my information and using the site, I agree to the Privacy Notice and Terms of Use.

By checking this box I acknowledge that I have read and agree with the Wholesale Practitioner Terms.

Thanks for getting in touch!

We appreciate you contacting us. Please make a practitioner account in the top right hand corner of the website, and then you're ready to begin shopping.

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. Please make a practitioner account in the top right hand corner of the website, and then you're ready to begin shopping.

Have a great day!

Application Form - Wholesale/Practitioners

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