New Account Setup Form

NEW ACCOUNT SET UP FORM

CREDENTIAL REQUEST
Designs for Beauty is excited to partner with Fagron Genomics US to bring you advanced genetic testing for beauty and wellness. Test kits and accounts are limited to credentialed healthcare professionals only.

Please fill and submit this form electronically, or contact us if a PDF form to print out and scan is preferred. The account holder’s name must match the medical license/certification name provided.
Provider Name*

First NameLast Name
Practice Name*
Website*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email Address*
example@example.com
Specialty / License*

MDDCDOPANDNPRDOther Specialty
Credentials (NPI or Other License Number)*
Please upload a photo copy of the license(s) stated above*

Cancelof
Sales representative that assisted you*
If "Other" Sales Representative is listed please provide their full name*
Weekly Patient Volume (Average)*
New to Genetic Testing?*

YesNo
What are the other labs services you've previously used?
Other Fagron Genomics US Interests?

Diet & Weight-Management (NutriGen)Athletic Performance (Sports Panel)Alopecia / Hair-Loss (TrichoTest)DNA / Biological Aging (TeloTest)Comprehensive NutriGenomics (Pro7)PharmacoGenomics (PGx)Methylation / Foundation / WellnessImmune / Auto-Immune / InflammatoryNeurological / PsychWomen's HealthMen's HealthDevelopmentalChronic PainNeurotransmitters / MoodGastrointestinalAutophagyDetoxificationPre-SurgicalTBI / Post-ConcussionEarly ChildhoodEssential VitaminsAll of the AboveUnsure / Don't Know YetOther

My Products*

Starter Kit FeeThe $15 fee covers two DNA starter kits and will be credited to your account for future orders once your account is set up (within 1-2 business days). Important: These kits are unpaid and cannot be discounted. Use them to introduce our services to your patients. If a sample is returned, standard pricing from the included menu will apply.

$15.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature*

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Date*

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Date
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NEW ACCOUNT SET UP FORM