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  • New Account Setup Form

    Please complete this ENTIRE form to avoid delay in service.
  • Contact Information

  • Contract Signatory Information

  • Practice Information

  • Customer Billing Information

  • Credit Card Information

  • ACH information

  • Payment Information

  • By its signature below to this application for credit, Applicant hereby agrees to the following terms and

    conditions of sale should HEALING RX LLC elect to extend such credit.

    1. Applicant shall pay for all items purchased and services rendered in accordance with the terms and conditions established by Healing RX LLC. Absent any written agreement to the contrary signed by both Applicant and Healing RX LLC payments for all purchases are due 30 days from date of invoice.
    2. All payments shall be made in form satisfactory to Healing RX LLC. Applicant shall pay a late payment charge of 1.5% or the maximum rate permitted by law, assessed monthly until paid in full on any amount not paid when due. Applicant shall also pay all losses, costs, attorney’s fees or other expenses incurred by Healing RX LLC as a result of Applicant’s failure to comply with the terms of this agreement. Failure or delay by Healing RX LLC to bill for any such late payment or other charge or expense shall not waive or otherwise affect Healing RX LLC the right to collect these charges.
    3. Healing RX LLC reserves the right at all times to limit or terminate the extension of credit and to modify its terms of sale.
    4. Applicant represents and warrants that all information provided in this application or otherwise submitted is true and correct and is being furnished for the purpose of obtaining/retaining credit from Healing RX LLC. When requested, Applicant shall provide Healing RX LLC with current financial statements and/or tax returns with all notes and schedules necessary to extend, review or adjust credit.
    5. As a condition of extending credit, Applicant agrees to provide valid and current credit card or ACH payment information, which Healing RX LLC shall securely store. If payment has not been received by the 30th day following the invoice date, Healing RX LLC is authorized to charge the full outstanding balance to the saved payment method on file. Applicant agrees that such charge shall be valid and enforceable as if made directly by the Applicant.

    Applicant represents and warrants that the information provided herein is true and correct. Applicant authorizes Healing RX LLC to contact any source necessary to determine Applicants credit worthiness.

    Applicant represents and warrants that this application has been executed by its authorized representative.

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