Medical Professional Login

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Are you interested in establishing your own UPS shipping account to benefit from Mediq Wellness's volume discount on shipping and handling costs? This can be used for any purchase from any vendor.
Account Information:
Your Email:
Create a password:
Password again:

Password Reminder Question:
Password Reminder Answer:

Referral:
How did you hear about us:
Referral Code:
Referred By:

Practice Information:
Doctor Name:
Practice Name:
Practice Phone:
Doctor Cell Phone:	(optional)
Practice Fax:
Practice Address:
Suite:
City:
State:
Zip:

Optional Questions to improve our ability to help your practice:
What companies do you presently purchase from?
Current Vendors:
What are the most common items used in your practice?
Common Items:

Shipping Information:

Confidentiality & Communications Statement:
Please note that in order to offer the benefits to members and the association, it is critical that the Mediq Wellness business model, benefits and pricing remain confidential. This prevents other vendors from attempting to disrupt the idea that Mediq Wellness has created which capitalizes on the exclusivity of Mediq products which are only available to medical professionals. By checking the box below, you agree that the information provided above is current and factual. You also agree to accept and receive email and/or fax communications regarding news, updates and specials from Mediq Wellness.
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