Health Care Professional Registration

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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 (available for laboratory services only, products must be purchased by credit card)  
When choosing this option, FLUIDS iQ® will invoice 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.


Please invoice me for 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®?