Dermafill Microbial Cellulose Wound Dressing

Distributor/Purchaser Application

We sell directly to distributors as well as end-users such as hospitals, nursing homes, etc. In order to view pricing/purchase you must submit the application below for our consideration.

Business Information

Business Name
Tax ID Number
Years In Business
Approx Annual Sales
Type of Business
Venue of Business -- Please Select -- Medical Dental Nursing Home Hospital Wound Care Center Physician's Office School Brick & Mortar Storefront E-Commerce Both Other

What facilities, if applicable do you service? Hospital
Nursing Home
Home Health Agency
Wound Care Center

Website Address
If Applicable

Contact Information

Contact Name
Email Address
Communication Preference Phone Email Mail Fax
Mailing Address
City, State & Zip
Shipping Address
City, State & Zip

General Information

Please describe your store and reason for application
(ie: become an approved retailer or learn more about our line)


Please list the top five other brands you carry


Comments for General Consideration


Please note all retail applications must be reviewed for acceptance. We have certain internal standards and contracts in place that prevent us from accepting all applicants. Once we receive your application, we will review it in a timely manner and get back to you as soon as possible with the status of your application.