Name: Vivrelle
Price range: $

Start your application step 1/5 edit

Email ${ errors.first('account.email') }

Password ${ errors.first('account.password') }

Referral Code Did an influencer or friend give you a referral code? Enter that here.

Success! ${selectedPromoCode.code} will be applied on your first invoice for ${selectedPromoCode.description}

Tell us about you step 2/5 edit

Birthday

We use your birthdate to verify your age. ${ errors.first('personalize.fields[memberBirthday][date]') }

Social Media (Optional)

We would love to follow you! Enter your account handles or links below.

${ getFirstErrorByRule('personalizationSocialMediaHandles') }

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Shipping Information step 3/5 edit

First Name

Last Name

Address

Apt/ Unit / Suite

City

State

Postal Code

Phone Number

${ getFirstAddressScopeError }

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Payment Details step 4/5 edit

My billing address is the same as my shipping address

Address

Apt/ Unit / Suite

City

State

Postal Code

${ getFirstPaymentScopeError }

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Review Information step 5/5

Tell us about you edit

birthday: ${ [fieldModel.memberBirthday.substr(0,2), fieldModel.memberBirthday.substr(2,2), fieldModel.memberBirthday.substr(4)].join('/') }

SOCIAL MEDIA

Shipping Information edit

Payment Details edit

${ fieldModel.firstName } ${ fieldModel.lastName }
${ fieldModel.shippingAddress }
${ fieldModel.shippingAddress2 }
${ fieldModel.shippingCity }, ${ fieldModel.shippingState } ${ fieldModel.shippingPostalCode } ${ fieldModel.memberBillingAddress }
${ fieldModel.memberBillingAddress2 }
${ fieldModel.memberBillingCity }, ${ fieldModel.memberBillingState } ${ fieldModel.memberBillingPostalCode }

${ fieldModel.card_brand }

ending in ${ fieldModel.card_last4 }
exp: ${ fieldModel.card_expiry }

I agree to pay for 3 months of membership fees if I decide to cancel prior to then.

I have read and agree to the membership agreement, terms of use, and privacy policy.

Sign me up for Vivrelle promotional emails.

${ getFirstTermsScopeError }

Thank You!

We’re reviewing your application and will be in touch once the status of your application has changed.

Be on the lookout for an email confirming your account! And don’t worry, your card will not be charged until you have been accepted and select your first item.

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