Practitioner's Registration Form

Please complete the form below to register as a practitioner member to begin using our herbal dispensary services. All fields marked with an asterisk (*) are mandatory.

Practitioner Member Contact

* First Name:

* Last Name:

Clinic / Company Name:  

* Address:

Address 2:

* City:

* Postal Code:

* Prov/State:

* Country:

* Phone (Main):

Fax:

Cellular:

Other:

* E-mail:


Billing Contact

  Billing Contact same as Practitioner Member Contact?

* First Name:

* Last Name:

Clinic / Company Name:  

* Address:

Address 2:

* City:

* Postal Code:

* Prov/State:

* Country:

* Phone (Main):

Fax:

Cellular:

Other:

* E-mail:


Shipping Contact

  Shipping Contact same as Practitioner Member Contact?   - OR -

  Shipping Contact same as Billing Contact?

* First Name:

* Last Name:

Clinic / Company Name:  

* Address:

Address 2:

* City:

* Postal Code:

* Prov/State:

* Country:

* Phone (Main):

Fax:

Cellular:

Other:

* E-mail: