practitioner registration page

New User Registration

Choose a Username*

First Name*

Last Name*

Clinic/Company Name

Day Phone*

Cell Phone

Updates/Specials Via Text Message?

Email*

Address 1*

City*

Address 2

State*

Zip*

Country*

Do you have a store front, e commerce site, both, or neither?*

Social Media Handles

Tax ID Number Or EIN Number *if you are using your SSN please call 1-800-445-4647*

How do you plan on using the products?

How many patients do you see a month?*

Attached License or Certification Here*

How long have you been in practice?*

What Kind Of Practitioner Are You?

How did you hear about us? Practitioner Referral?*

Resale Policy

Resale Certificate Number or Tax Exempt Number

Upload Resale Certificate Or Tax Exempt Document

If Your State Is Exempt From Taxes Please Check The Box Below

Electronic Signature*

*Required field