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 user login and password.

* required fields
Contact information

Billing and Mailing Information:

Shipping Address (if different from billing information)

Example: (123)-456-7890

Patient Referral
* Credit Card Authorization

Practitioner Certification
Certification must be emailed as an attached jpg, gif, png or tiff file - or - faxed to us at 1-866-881-2888

* Please indicate how you heard about us:
* Please indicate your interests:
* Please check all that apply:

* Please check all that apply:

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

* Do you plan to resell our products online?

* Terms and Conditions - (please see the link provided at the bottom of this page, opens in a new window)