Healthcare Professional Registration

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To create a new account, please complete the form below and then click "Register"

To ensure prompt delivery of your order, please be sure to include Suite/Floor Number if applicable.

Fields with * are required.

Email*

Password*

Confirm Password*

Prefix*

First Name*

Last Name*

Office Address*

Suite/Room/Floor (leave blank if n/a)

Office or Medical Complex name (if applicable)

City*

State*

Zip*

Phone*

Specialty*

Please mention other speciality here

NPI* https://www.npinumberlookup.org

Where did you learn about our website?*

Please mention where you learnt about our website

Checking this box certifies that I am a licensed healthcare professional in the above state, and I have requested to be mailed the indicated samples for the medical needs of my patients. Further, I understand that these products cannot be sold, traded, bartered, returned for credit, or utilized to seek or obtain reimbursement. I agree that these samples will not be submitted to any third-party payor, public or private (including, without limitation, Medicaid, Medicare, private insurers, or other third parties), for reimbursement.*

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Healthcare Professionals