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Name of your Medical Practice*

Office Contact Name*

First Last

Your Email*

Provider Name*

First Last

MD/DO*

Provider Address*

Street Address Address Line 2 City State ZIP Code

Provider Email*

Provider Phone

Provider Website*

Medical License*

Provider % & Patient Discount*

You decide how to use your 30% commission

NEEDS , WANTS & DESIRES

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

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

Beyond Balance*

E-Mail	Username	Account Name or Number

BioPure*

E-Mail	Username	Account Name or Number

Byron White Formulas*

E-Mail	Username	Account Name or Number

Emerson Ecologics*

E-Mail	Username	Account Name or Number

GreenDragon*

E-Mail	Username	Account Name or Number

lauricidin*

E-Mail	Username	Account Name or Number

MegaSporeBiotic*

E-Mail	Username	Account Name or Number

NeuroScience*

E-Mail	Username	Account Name or Number

Ortho Molecular*

E-Mail	Username	Account Name or Number

Prescript Assist*

E-Mail	Username	Account Name or Number

Seeking Health*

E-Mail	Username	Account Name or Number

Xymogen*

E-Mail	Username	Account Name or Number

Are You on MD HQ

Yes
No

Would you like fullintegration

Yes
No

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

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