New Account Application

Qualified health practitioners are welcome to register through the Biomed website, or download an application form PDF here. Once approved, an email will be sent to you with confirmation and your Biomedicine.com user login and password.

Not ready to apply for an account? Click here to arrange a consultation with one of our Education and Medical Support Specialists.

Contact information

Clinic Name *

Prefix

Practitioner Name *

Designation *

Billing and Mailing Address:

Bill-to Street *

Bill-to Unit

Bill-to City *

Bill-to Province/State *

Bill-to Postal Code/Zip *

Bill-to Country *

Shipping Address (if different from billing information)

Ship-to Street

Ship-to Unit

Ship-to City

Ship-to Province/State

Ship-to Postal Code/Zip

Ship-to Country

Email *

Website

Phone *

Example: (123)-456-7890

Authorization

Please notify me by business email when Education Events, Special Products and Exclusive Media Resources become available.

Credit Card Authorization *

All order transactions are conducted by Credit Card. I authorize Biomed to use the credit card information that I will provide to the sales desk to process pre-authorization and payment for the orders that I request. The information I will provide is confidential and only to be used in processing order payments to my account.

Practitioner Certification Or Student ID

Certification of Student ID

Please upload your certification or student ID here. Alternatively you can email it to approvals@biomedicine.com.

Please indicate how you heard about us *

Please indicate your interests *

If you checked Sales Rep - please indicate which rep?

Product(s) of interest to you

Internet resellers must have a valid Minimum Advertised Price Agreement in place.

Do you plan to resell our products online? *

Yes
No

Terms and Conditions *

I have read the Terms and Conditions of this web site, ordering page and account information uses indicated on the Terms of Use Page and I accept the liability limitations outlined therein.

Order online or call: 1-800-665-8308

Order online or call:
1-800-665-8308