PLEASE fill out this form and fax back with a copy of your license or certification.

NEW ACCOUNT FORM

Date:_____________ Contact Name:______________________________________________
Account Name:________________________________________________________________
Degree of Account Holder: ______________________________________________________
License #: ____________State of Issue: ____________________________________________
How did you hear about Biotics Research Corporation? ______________________________

BILL TO:
Address: _____________________________________________________________________
City, State, Zip: _______________________________________________________________

SHIP TO:
Address: _____________________________________________________________________
City, State, Zip: _______________________________________________________________

CONTACT INFO:
Phone#: __________________________Fax#: ______________________________________
Email Address: _______________________________________________________________

METHOD OF PAYMENT:

*********Please note the first order must be prepaid by credit card or COD************
Credit Card#: _________________________________________exp: ___________________
Cardholder Name: ____________________________________________________________
1st order only _________________Keep on file ________________COD ________________

*****Please call Customer Service at 1-800-231-5777 to set up internet access to our website for online ordering. If you have already created a New Account on website check here to be activated: ___________
REQUEST FOR TD ACCOUNT – allows patients to call directly (Call Customer Service For Details)