Hospital Account Registration

Hospital Account Registration

Use the form below to set up a new hospital account. For home use visit Order Now.

New accounts: Submit the form below and a Medolac Representative will contact you within 24 hrs, M-F.
Existing accounts: Send us your completed Purchase Order: Fax: 866.239.3654 or Email: order@medolac.com

Billing Information

Account Type *

Contact Name *

First

Last

Job Title *

Email *

Legal Business Name *

DBA (if applicable) *

Primary Phone Number *

Extension *

Secondary Phone Number *

Extension *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Invoicing Method *

Preferred Payment Method *

Fed Tax ID Number *

Shipping Info

My shipping address is same as billing *

Yes No

Destination Name *

Contact Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Accounts Payable Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax Number *

Purchasing Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax *

Clinical Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax *

Implicated Products Emergency Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax *

Submit

CONTACT US:
Phone: 1(866) 599-7740
Email: info@medolac.com

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