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Physician Registration

Fill out the form below and we will contact you with a personal password that can be used for both online and phone orders. In addition, please fax a copy of your professional license to Wellness Pharmacy at 800-369-0302. (required).

Clinic Name:
Salutation:
Dr. Mr. Mrs. Ms.
First Name:
Last Name:
Phone:
Address 1:
Address 2:
City:
State / Zip Code:
/
Country:
Email:
Website:
   
Professional Degree or Certification:
* Please fax license to Wellness Pharmacy: 800-369-0302 (required)
Specialties or Area(s) of Interest:
How did you hear about us?
   
Would you like to be added to our EssentialPRO™ physician’s referral list? YES NO

Terms & Conditions:

Please check the box below to certify that you are a licensed healthcare professional and that the issued password will be for the use of only yourself and your staff to place orders:

Check to agree to the above conditions

   
    

   
 

Already Registered?
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Essential Nutraceuticals, LLC  .  3401 Independence Drive #231  .  Birmingham, AL 35209