New Customer Professional Form
Practitioner's Name:
Business or Clinic Name:
Phone Number:
Email Address:
Fax Number:
Mailing address:
Shipping address:
Tax ID number:
Type of Practitioner	Medical Doctor Naturopathic Doctor Naturopathic Physician Acupuncturist Chiropractor Chinese Medicine CBP CNP DDS Dermatologist Dietician DO Homeopathist Herbalist LPN Massage Therapist Midwife Nutritionist Pediatrician OB/GYN RN Body Work (other) Veterinarian other
Select what you use in your practice:	Homeopathic Remedies Nutritional Supplements Herbal Medicine Muscle Testing BioMeridian machine Other Testing Devices

UPS Ground	***PRIMARY METHOD OF SHIPPING*** Rates vary by location & weight of package
UPS 3 Day Select	Upon Request - Rates vary by location & weight of package **Call for a quote**
UPS Second Day Air Saver	Upon Request - Rates vary by location & weight of package **Call for a quote**
UPS Next Day Air	Upon Request - Rates vary by location & weight of package **Call for a quote**
USPS Priority Mail (to PO Boxes & Hawaii)	Upon Request - Rates vary by location & weight of package
International Orders (UPS or USPS)	Rates vary by location & weight of package **Call for a quote**
FREE SHIPPING	For orders totalling over $300 (commercial delivery) For orders totalling over $350 (residential delivery)
Patient Drop Ship Orders	$3.00 Drop Ship Fee in addition to shipping No invoice is sent to the recipient. All invoices are charged to you, the Physician. Convenient way to keep low inventory.