Physician Registration

Facility Name *

Healthcare Professional Name *

State Medical License Number *

State Medical License Expiration Date *

First Name *

Last Name *

Email *

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Address 1 *

City *

State *

Postcode *

Phone *

What is the medical specialty of your practice? *

What is your estimated annual order volume? * 6-50 bottles50-100 bottles100-1000 bottles1000-5000 bottles5000+ bottles

Who will you be distributing the product to? *PatientsRetail consumersOther wholesale distributors

Do you ship product to any countries outside of the US? If so, please list them. *

Do you sell products online? *YesNo

If you have a website, please list it here *

I certify that I am a healthcare professional with a current medical license and prescribing authority. I have requested these products for use by the patients of my practice. I acknowledge that it is my responsibility to dispose of or return any damaged and/or expired products to Colorado Biolabs, Inc. in accordance with state regulations. *Yes

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