Welcome to the pilot.

Let's get you set up.

A few details to begin. Once submitted, this form starts your onboarding workflow — you'll receive sequenced emails from your Onboarding Manager guiding you through each remaining step.

01

Practice Information

Basic details about your practice and the technology you use today.

Business/Practice Name *

Practice Management System *

Locations (Optional)

02

Business Information for SMS Registration

Required for A2P 10DLC carrier registration so we can send compliant SMS reactivation messages on your behalf. Collected now because carrier review can take days to weeks.

Business Name *

Enter the exact business name, as registered with the Government and mentioned in your tax documents (W2, W9 or CP 575). E.g. Name of Business LLC rather than Name of Business.

Business Type

Business Registration Number (EIN)

Please enter your US EIN number based on where your business is registered. It must be a 9-digit number (e.g., 12-3456789). US customers who do not have a tax ID need to register for one with the Internal Revenue Service (IRS). A2P Brand registrations using newly generated US EINs (registered in the last 45 days) may be rejected by TCR.

Practice Website *

Business Email *

Address

City

State

Postal Code

03

Pilot Configuration

A couple of decisions that shape how the pilot runs for your practice.

Match the $50 Revance rebate?* *

Yes, match it ($100 total to patient)

No match ($50 Revance rebate only)

Decide at Baseline (Discuss with Onboarding)

CRM User Roster

04

Agreement & Acknowledgment

Your acknowledgment kicks off the technical workflows behind the scenes — credential collection, data integration, CRM setup, and A2P registration all begin from this point.

First Name

Phone *

Email *

Last Name

I am authorized to enroll this practice in the Revance × DermPRO pilot and confirm I have reviewed (or will review with counsel) the pilot onboarding terms and the Business Associate Agreement governing data access, patient privacy, and the 6-month engagement.