29300-191

This application is for facilities and practices located in the United States and Canada only. For all other countries, please Contact Sales.

This form is for United States and Canada applicants only. Non-US applicants should contact sales to learn more. Approvals can take up to 5 business days and additional information may be requested.

Clinic/Hospital Name*

Billing Address*

City*

State*

Zip*

Country*

Email for Invoices*

Buying Affliation*

Examples: HCA, Novation, etc.

Federal ID*

Tax Exempt*

Is the facility exempt from paying sales tax?*

Yes

No

Hidden

Preferred Shipping*

Our FedEx Account

Our UPS Account

Epimed's FedEx

Epimed's UPS

Hidden

Carrier Account No.*

Upload Tax Exempt Certificate*

Accepted file types: pdf, png, jpg, Max. file size: 1 MB.

IHR-530 Rev. 13

Please provide a primary shipping address.

Shipping Address*

City*

State*

Zip*

County*

Country*

Telephone*

Fax

IHR-530 Rev. 13

Primary A/P Contact*

Phone*

Email*

Add more contacts?*

Yes

No

Please select:

Purchasing Agent

Materials Manager

Nurse

Risk Manager

Other Contact

Purchasing Agent

Phone

Email

Materials Mgt

Phone

Email

Nurse

Phone

Email

Risk Manager

Phone

Email

Other

Phone

Email

IHR-530 Rev. 13

Physician Office*

City*

State*

Postal Code*

Country*

Email*

Telephone*

Fax

IHR-530 Rev. 13

Physician First Name*

Physician Last Name*

Degree*

Pain Practice Specialty*

IHR-530 Rev. 13

Name

This field is for validation purposes and should be left unchanged.

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