Register New Account

Business or Client Name *
Contact Name *
Phone *
License Number *
Membership in Good Standing *
If Other Please Provide
Are you registering as an Individual Practitioner or as a Clinic? *
If registering as a clinic please indicate the names and license numbers of all ordering Naturopaths.
Address *
City *
Postal Code *
Administrative/Office Contact
Result Email Address *
Critical Results Reporting 24 Hour Phone Number *
Optional: Secure Fax
Invoicing Details
Invoicing Address
Invoicing City
Invoicing Postal Code
Invoicing Phone
Invoicing Accounting Contact
Payment *
Email Opt In
Email *
Terms and Conditions *