MAG49

Name of your Medical Practice*

Office Contact Name*

First Last

Office Contact Email*

Office Phone Number

Provider Name*

First Last

MD/DO*

Explain other: (NutrimentRx is only for MD/DO and ND from one of the 3 recognized institutions)*

Provider Address*

Street Address Address Line 2 City State ZIP Code

Provider Email*

Provider Website*

Medical License

Medical License #*

NEEDS , WANTS & DESIRES

What can we to to honor the offerings you want to provide your patients

What Vendor Partners are you interested in offering your patients?

Select all that apply. ***NutrimentRx requires all Providers who register with us, to have accounts established with every vendor partner you desire to offer your patients. (Note NutrimentRx can assist and streamline this process inquire if applicable)

Do you currently have accounts setup with any supplement providers?

If not NutrimentRx requires you to meet the requirements of each and every vendor partner you choose to offer. NutrimentRx can assist in a streamlined registration process.

NutrimentRx requires all Providers who register with us, to have accounts established with every vendor partner you desire to offer your patients. (Note NutrimentRx can assist and streamline this process inquire if applicable)

Apex Energetics*

E-Mail	Username	Account Name or Number	Password

Beyond Balance*

E-Mail	Username	Account Name or Number	Password

BioPure*

E-Mail	Username	Account Name or Number	Password

Byron White Formulas*

E-Mail	Username	Account Name or Number	Password

Emerson Ecologics*

E-Mail	Username	Account Name or Number	Password

GreenDragon*

E-Mail	Username	Account Name or Number	Password

lauricidin*

E-Mail	Username	Account Name or Number	Password

MegaSporeBiotic*

E-Mail	Username	Account Name or Number	Password

NeuroScience*

E-Mail	Username	Account Name or Number	Password

Ortho Molecular*

E-Mail	Username	Account Name or Number	Password

Prescript Assist*

E-Mail	Username	Account Name or Number	Password

Seeking Health*

E-Mail	Username	Account Name or Number	Password

Xymogen*

E-Mail	Username	Account Name or Number	Password

Are You on MD HQ

Yes
No

Would you like full integration?

Yes
No

This means the supplements you place in your MD HQ notes will be placed in your patient's cart at NutrimentRx

Who do you currently use for your supplement needs?

Number of New Patients Per Week*

Please enter a value between 0 and 100.

Number of Active Patients in Practice*