Registration Form

Creating an account with us allows you to use all of our online services. Once logged in, our website provides you with complete access to our product descriptions, price lists, order forms and more. Simply complete the registration form and we will get your account set up once we have verified your details.

User Information

You have selected the Practitioner registration.

Select this level if you are a Practitioner.

Account Information

Username

Email Address

Confirm Email Address

Password

Confirm Password

Full Name LEAVE THIS BLANK

Already have an account? Log in here

Your Name

First Name

Middle Initial(s)

Last Name

Email/Web

Alternate Email

Your Website

Practitioner License Information

Educational Institution

License Number

Years In Practice

Business Details

Enter the Contact Details for your Practice or Business

Clinic Name

Type of Practice

Business Phone

Cell Phone

Fax

Business Address

Enter the Address where your Practice operates

Street Address

City

Prov / State

Other Prov / State

Postal / ZIP

Country

Different Shipping Address?

Shipping Address

Shipping City

Shipping Prov / State

Shipping Other Prov / State

Shipping Postal / ZIP

Shipping Country

Billing Address

First Name

Last Name

Address 1

Address 2

City

State

Postal Code

Country

Phone

Payment Information

Card Number

Expiration Date

Security Code (CVC)

I agree to the Registration Terms of Service

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A. 50 Eileen Stubbs Ave, Unit 144
Dartmouth NS B3B 0M7