Login
Register
Login*
Password*
Lost password
Login*
E-Mail*
Password*
Password repeat*
SHIPMENTS & DELIVERY
Referral Name*
Clinic Name*
Clinic Shipping Address*
Street Address Line 2
City
State / Province
Postal / Zip Code
MEDICAL LICENSE INFORMATION
Medical License Holder Name*
Medical License Holder Credentials*
MD
DC
DO
ND
NP
PA
DDS
Please Select
Practitioner Phone Number
Practitioner Email*
NPI*
Medical License Number*
Medical License Address*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I acknowledge that I have read and understood the above information/requirements, and am a medically licensed professional, and will not resell or distribute any products ordered. IMPORTANT: By signing this consent form, you acknowledge that any products that the FDA has not provided pre market approval for are considered investigational and/or experimental and/or for research use, and as such do not have the ability to be legally advertised in any way that makes claims about their safety or outcomes. This disclaimer applies to both peptides and biologics as defined by the FDA, including but not limited to birth tissue allografts and peptides/biologics created from amino acid sequences. Please consult your legal counsel for any questions regarding the governance of your state medical license as it pertains to the uses of such non-FDA Approved biologics.