*Company/Practice Name:_____________________________________________
*First Name:_____________________________________________
*Last Name:_____________________________________________
*Address 1:_____________________________________________
Address 2:_____________________________________________
*City:_____________________________________________
*State:_____________________________________________
*Zip:_____________________________________________
*Phone 1:_____________________________________________
Phone 2:_____________________________________________
Fax:_____________________________________________
*Email:_____________________________________________
*Proof of Professional Affiliation: Letterhead    Business Card    Copy of License    Other
Doctor's Pride sells exclusively to health care professionals and Proof of Professional Affiliation (accepted forms listed above) is required. Print this form out and fill in all required fields.

You may fax completed form with Proof of Professional Affiliation to 800-397-4252, or you may email completed form to customerservice@doctorspride.com (attach Proof of Professional Affiliation).

We will respond quickly via email, and once approved we will provide a USERNAME and PASSWORD.
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