If you are interested in applying for an account, please submit the following information.

Facility Information
Facility Name:


Contact Name:


Billing Address:

 
 
 
Shipping Address: (if different than billing)
Phone Number:


Fax Number:


Does your facility handle all measuring, fitting, and follow up services?
Yes    No


Will your facility be providing insurance billing services for the patient?
Yes    No


What certification or degree does your staff hold?


Resale Certificate Number (if applicable)


 
Accounts Payable Information
Accounts Payable Contact

Accounts Payable Phone Number

Accounts Payable Fax Number

Tax ID#

 
Three References
(three not required but strongly suggested)
Reference 1

Company or Name:


Phone Number:


Account Number: (if applicable)


Reference 2

Company or Name:


Phone Number:


Account Number: (if applicable)


Reference 3

Company or Name:


Phone Number:


Account Number: (if applicable)


 
Online Account
(this information only needed if you want access to the Distributor's Corner download area)
Email:


Desired Password: