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Request for Account

Please fill out the following information to obtain access to website and pricing. Once your account is approved, we will send account access information within 1-2 business days.

Store/Clinic Name

Address

City

State

Zip

Phone

Email

Do you wish to be on our email list for specials?
Yes No 

Website

Owner's Name

Store Contact/Purchaser

Years in Business

If your business is located in California, we require your resale number:

SR/#

The California resale certificate located at http://www.boe.ca.gov/pdf/boe230.pdf also must be filled out completely and faxed to 408-363-0700 or scanned and uploaded.

Upload resale certificate file

We do not provide credit terms. All orders are paid through the website when placed. Shipping charges will be adjusted to reflect actual UPS ground service charges.