New Account Form Name of Primary Contact for Account * First Name Last Name Email * Cell Phone for Emergencies * (###) ### #### Clinic Main Phone * (###) ### #### Clinic Legal Name * Clinic DBA if you use one Clinic Main Address Address 1 Address 2 City State/Province Zip/Postal Code Country Clinic Additional Addresses Please list all additional clinics that will recieve goods in the below format. Account Usernames and Passwords for Distribution Log Ins * *** Information only used to audit all purchases Approval for purchasing Rx & Rx device * *** DEA is for approval to purcahse pharma and Rx device items Thank you!
