Health Care Professional Registration


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First Name:
Please capitalize first letter of first name
Last Name:
Please capitalize first letter of last name
Clinic Name:
(cannot be a post office box)
Country / Zone:
Email address:
Username: Your email address is your Username
Password: ReqiuredMinimum number of characters not met.Exceeded maximum number of characters.The password doesn't meet the specified strength.
Password must have 8 - 16 characters (at least one number and one capital letter)
Confirm password:
Credit Card Information (Visa, Mastercard: For third party payment validation purposes only)
Credit card No:
Expiry Date:    
Billing First Name:
Billing Last Name:
Billing Street No.:
(the number that the issuing bank has on file)
Billing Street Name:
(the address that the issuing bank has on file)
Billing City:



Payment Method

Pre-authorized credit Card

When choosing pre authorized credit card, the card on file is charged for FLUIDS iQ® products and for laboratory services upon arrival of sample(s) to the laboratory in advance of analysis.
A valid Visa or Mastercard will be required to be put on file upon reception of first sample for analysis.

I authorize FLUIDS iQ® Inc. to charge my credit card for products purchased and laboratory services requested

Preferred language of communication
(ie: invoices, purchase receipts)
Yes, I would like to receive e-newsletters and product information from FLUIDS iQ®
How did you hear about FLUIDS iQ®?

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