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Practitioner Account Application

Application for an account to order NuMedica® products.
Please note: You must be a licensed health care practitioner to open an account with NuMedica®.  If you would like to be referred to health care practitioners in your area who work with NuMedica®,
 Please click here to visit our Clinician referral page.
*** All new accounts will be contacted for printed verification of professional credentials.***

 Bill To Information:

* Indicates Required Field

 

Account # (if new, type “NEW”): *

First Name: *

Middle Initial: *

Last Name: *

Degree (you must be a health care clinician): *

 

Clinic Name:  

Clinic Address (No P.O. Boxes): *

Clinic Address (line 2): 

City: *

State: *

Zip: *

Phone: *

Fax:  

E-mail Address: *

Is this a residential address?  

What is your preferred method of payment? 

Name of person who will most often order: *

 

 

 Ship To Information:

  Is the “Ship To” address the same as above?
If not, uncheck box & enter “Ship To” info. below. Otherwise leave checked and skip to next section.

Ship To Name: 

Address:

Address Continued:

City: 

State:

Zip:

Phone:

Is the Ship To Address residential: 

 

 

 

 

 Additional Comments:

 


Type your comments here:
(Do not type any sensitive information like credit card numbers in this box.

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