Sombra Cosmetics Referral Listing


	Referral Listing

We are looking for health care professionals who sell Sombra Natural Pain Relieving Gels direct to consumers. If you would like to be listed as a referral for your local area please completely fill out the form below. A Sombra representative will follow up with you to confirm your listing.

Business Name		Contact Name

Business Phone	Email Address

Business Address			Suite/Unit #

City	State		Zip Code


Website	Business Hours

What type of business do you have?
Chiropractic		Acupuncture
Physical Therapy		Medical
Massage Therapy		Other

What Sombra Natural Pain Relieving Gel do you offer for retail sale?
Original Warm Therapy		New Cool Therapy

What size(s) do you offer for retail purchase?
8oz.		4oz.
3oz. (Roll-On)		2oz.
1/2 oz

Is the address listed above a retail walk-in establishment? (i.e. must be able to walk in during regular business hours without knocking)
Yes		No

What social media network sites do you use?
Facebook		Twitter
MySpace		Other
Comments:



Thanks for registering!