Distributor Form

Before Filling out the Form Please Note:

If you sell exclusively to post-acute (not hospital inpatient, HOPD, or ASC), please click here to visit Venture Medical and then click on Apply to Sell for Venture. 

For all other distributors that sell into hospital inpatient, HOPD and/or ASC, as well as other areas, please fill out the form below and one of our representatives will contact you to discuss further. Thank you.

Contact
Information

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info@biostemtech.com
(954) 380-8342

2836 Center Port Circle
Pompano Beach, FL 33064

Distributor Form

Interested in being a distributor?

Your Name(Required)

First Last

Company(Required)

Email(Required)

Website

Your Phone(Required)

Best Time to Call You

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Choose One

Wound Care Products

Surgical Products

Wound & Surgical Products

What Places of Service do you sell into?

For distributors that also sell into hospital inpatient, HOPD and or ASC.

Click all that apply:

Hospital Inpatient

HOPD

ASC

Skilled Nursing

Mobile

Private Practice

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