sayphafiller.ca  |  renellence.com
CUSTOMER ONBOARDING FORM
Please complete every section. Fields marked * are required.
1 Clinic
Clinic name *
Hours of operation

Billing address
Street *
Postal code *
City *
Province *

Shipping address
Street
Postal code
City
Province

2 Account contact

Who we contact about orders, invoices and shipping. This person does not sign.

Full name *
Email *
Telephone *
3 Primary injector

The clinician who will administer product.

Full name *
Email *
Telephone

Registration no. *
4 Medical director

Full name *
Email *

Registration no. *
5 Authorization & signature
Receive product updates and offers by email?

After you submit, a signing link is emailed to

All signatures are required before your account opens.

All information is kept confidential.

Thank you

We’ve emailed a copy of your submission along with a link to review and electronically sign your onboarding agreement.