Contact Us

SECTION 1 — BUSINESS DETAILS

Company Name:

Trading Name (if different):

Type of Business:
PharmacyWellness ClinicMedical PracticeResearch FacilityOnline StoreDistributorOther

If Other, please specify:

Years in Operation:
0–11–33–55+

SECTION 2 — CONTACT DETAILS

Primary Contact Name:

Position/Title:

Phone Number:

WhatsApp Number:

Email Address:

Website (if applicable):

Physical Address:

Shipping Address (if different):

SECTION 3 — BUSINESS OPERATIONS

Business Model:
Retail StoreOnline SalesClinic UseDistributor/ResellerOther

If Other, please specify:

Estimated Monthly Purchase Volume:
R5,000 – R10,000R10,000 – R25,000R25,000 – R50,000R50,000+

Primary Product Interest:
Longevity ProductsRecovery ProductsWeight ManagementSkin & Aesthetic ProductsCognitive SupportFull Product Range

Do you currently stock peptide-related products?
YesNo

If yes, please list brands:

SECTION 4 — SALES CHANNELS

Where will products be sold?
Retail StoreClinicOnline StoreSocial MediaDistributor NetworkOther

If Other, please specify:

Do you intend to resell internationally?
YesNo

If yes, list countries:

SECTION 5 — COMPLIANCE & DECLARATION

Important Compliance Statement

I confirm that:

All products purchased will be used strictly for research or approved purposes only

Products will not be marketed for medical or therapeutic claims

All regulatory and safety standards will be followed

Accurate storage and handling procedures will be maintained

Confirmed