AI Wellness Platinum Network – Brand Onboarding Sign-Up Form
AI Wellness Platinum Network – Brand Onboarding Sign-Up Form
Brand & Company Information
Brand Name
*
Company Name (if different)
Website URL
Business Address
*
Business Address
Business Address
Business Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Business Address
Primary Contact Name
*
Email Address
*
Phone Number
*
Any Social Media Handles (Instagram, LinkedIn, etc.)
Company Type
*
Medical Device Company
Wellness & Supplement Brand
Fitness Technology / Wearable Brand
AI & Health Software Company
Aesthetic or Longevity Clinic
Wellness Service Provider
Other
Other
Core Value Alignment with AI Wellness (Select All That Apply):
AI-Driven Health Optimization
Longevity & Biohacking
Precision Wellness Solutions
Integrative Medicine & Alternative Therapies
Fitness & Performance Enhancement
Product/Service Details & Regulatory Compliance
Product Category (Select All That Apply)
*
Medical Device
Supplement
Therapy / Treatment
AI-Powered Health & Wellness Service
Digital Health or Software Solution
Other
Other
Regulatory Approvals
*
FDA-Cleared
FDA-Approved
CE Mark (Europe)
Health Canada Approval
ISO Certification
GMP Certification
Pending Approval
No FDA Approval (Categorized Under Wellness)
Scientific Research & Clinical Trials:
*
Published Clinical Studies
Peer-Reviewed Research
Internal Testing & Validation
No Clinical Studies Yet
Upload Supporting Documents (Research, Certifications, or Approvals)
Business Model & Revenue Strategy
Who is Your Primary Target Audience?
*
Consumers (DTC – Direct to Consumer)
Healthcare Professionals (Doctors, Clinics, Med Spas)
Corporate Wellness & Employee Health Programs
Fitness & Performance Experts
Longevity & Biohacking Communities
Other
Other
Current Revenue Model
*
Direct-to-Consumer (E-commerce, Subscriptions)
B2B Partnerships (Wholesale, Licensing, Clinics, Gyms)
Marketplace Model (Already listed or interested in AI Wellness Marketplace)
Retail & Distribution (Physical locations, medical offices, corporate wellness)
Estimated Monthly Production Capacity
Projected Annual Revenue from AI Wellness Integration (Optional):
AI Wellness Integration & Digital Avatar Creation
Do You Already Have a Digital Avatar for Your Brand?
*
Yes – We have an existing avatar (We will provide files)
No – We need to create a new AI-powered avatar
Preferred Avatar Creation Method:
*
Virtual AI Avatar Session (Remote Creation)
In-Studio Avatar Capture (Physical Location)
Upload Existing Avatar Files (If Available)
Would You Like Multi-Language AI Integration for Global Accessibility?
Yes
No
Compliance & Liability Information
Does your product require any liability disclosures or disclaimers? (For health, medical, or supplement products)
*
Yes – We have a pre-existing liability disclaimer (Upload Below)
No – Our product does not require disclaimers
Upload Liability Disclaimers, Terms & Conditions, or Safety Guidelines
*
Does your product/service require FDA or medical professional approval before use?
*
Yes – It must be administered by a certified professional
No – It can be used independently
Partnership & Sponsorship Opportunities
Would you be interested in sponsoring AI Wellness events, digital screens, or media platforms?
Yes – We would like sponsorship & advertising opportunities
No – Not at this time
Would you like to explore exclusive partnership opportunities for AI Wellness Pavilion & Events?
Yes – We would like to discuss premium partnerships
No – We are only interested in product listing & content integration
Are you open to affiliate or revenue-sharing opportunities with AI Wellness?
Yes – We are interested in commission-based sales models
No – We prefer a direct sales model
Final Confirmation & Disclaimer
The information provided is true, accurate, and complete to the best of my knowledge.
My brand has the legal authority to enter into an agreement with AI Wellness Platinum Network.
AI Wellness reserves the right to verify all submitted materials and deny participation if eligibility requirements are not met.
•Any false or misleading information may result in disqualification from AI Wellness Platinum Network programs.
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