Physician Name *

First Name

Last Name

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have an active practice? *

Yes

No

Are you part of a group or a single practice? *

Group

Single

Do you perform AK, EDS, or NRT testing? *

Yes

No

Telephone *

(###)

###

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*

I understand that new accounts are opened only for health care professionals in the U.S. territories. By checking this box, I certify that the information provided above is true and correct to the best of my knowledge, information, and belief, submitted after diligent inquiry and that I am authorized to sign on behalf of the applicant.

*

I understand that before this registration can be processed, we need you download, read, and sign our Customer Protection Agreement. The Customer Protection Agreement is located at the bottom of this form. You will not receive a customer number or access to our professional line of products if you do not provide us with a signed Customer Protection Agreement.