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NPI Number *

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First Name *

Last Name *

Title / Role *

Phone *

Does the Owner of the NPI number match the contact for this account? 

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If No, I acknowledge I will be required provide written approval from the owner of the NPI number prior to the account being approved *

Street Address *

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Postcode / ZIP *

Medical Director / Supervising Provider Name 

License Type & License Number 

State(s) Licensed In 

For clinic use initial EACH statement below 

Products ordered are for clinic use only

Clinic acknowledges products may be designated Research Use Only (RUO)

Clinic agrees to comply with all applicable federal state and local laws

Manufacturer reserves the right to approve deny or revoke ordering privileges at its discretion

Authorized Representative Name *

Date *

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