Cadira is a great dog with a brother named Jake. Form Preview
  • If you have not already done so please print off the Acknowledgement and Signature Form and have each physician sign and upload it at the bottom of this page.

    Once you have completed and submitted this form, we will enter the practice and physician(s) into our system and then generate a welcome email and send directly to the office contact you enter on this form. This email will include information on how to access our portal and provide them with their login credentials. The same day the registration packet is received, I submit a request to our shipping department for supplies. The supplies take 3-4 business days to arrive at the practice. When practices go to order more supplies, it's important to keep this shipping window in mind. If for any reason a practice runs into a bind, we're more than happy to over night supplies.

    CLICK HERE if you need to print the physician acknowledgement form.

    NOTE: The individual who directed you to this registration form should have provided you with their "Group ID". If you did not receive this please find out the appropriate code before registering your Practice to help us organize our groups.

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  • Please select which services are being requested.

  • Physician Information

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  • Insurance Mix

    If you don't know please estimate and put a "0" (zero) if it does not apply.

  • Office Contact Person

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    Pick a Date
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