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

This form is for United States 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

Upload Tax Exempt Certificate*

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

IHR-530 Rev. 12

Please provide a primary shipping address.

Shipping Address*

City*

State*

Zip*

County*

Country*

Telephone*

Fax

IHR-530 Rev. 12

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. 12

Physician Office*

City*

State*

Postal Code*

Country*

Email*

Telephone*

Fax

IHR-530 Rev. 12

Physician First Name*

Physician Last Name*

Degree*

Pain Practice Specialty*

IHR-530 Rev. 12

Phone

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

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