Health Care Professional Registration

Note: If you already have an account with us, please proceed to the login page
 
Specialist type:
First Name:
Please capitalize first letter of first name
Last Name:
Please capitalize first letter of last name
Title:
Designation
Clinic Name:
Address:
(cannot be a post office box)
City:
Country / Zone:
State/Province:
Telephone:
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 (Cards accepted: Visa, Mastercard)
 
 
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 once tests are completed, reports are uploaded to the FLUIDS iQ® website and an email notification is sent to the health care professional.


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

   
Pay by cheque  
When choosing this option, FLUIDS iQ® will invoice twice monthly for FLUIDS iQ® products purchased and laboratory services performed in the preceding two week period.


Please invoice me for FLUIDS iQ® products purchased and laboratory services requested. I agree that FLUIDS iQ® Inc. reserves the right to charge the credit card on file if my account is not kept current.

   
Communication
   
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®?