New Account Form
Every licensed medical professional that will be purchasing these products will need to sign a copy of this consent. If you practice at multiple locations, a consent form is required for each location and location address must match license.Product(s) REQUIRE an appropriately licensed medical professional or authorized employee to sign for receipt of product(s If licensed medical professional or employee thereof does not sign for the product(s) at time of delivery, the product(s) could be rendered unusable. Heal Well Corp and our manufacturer partners are not liable for any loss that occurs due to no delivery or lack of signature.
Sales Representative Name
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First Name
Last Name
Sales Rep Email
*
example@example.com
Clinic Name
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Clinic Contact Name
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First Name
Last Name
Clinic Email
*
Phone Number
*
Clinic Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical License Information
Medical License Holder Name
*
First Name
Last Name
Medical License Holder Credentials: (ex: MD, DO, NP, PA, etc.)
*
Practitioner Phone Number
*
Practitioner Email
*
NPI#
*
Medical License Number
*
Medical License Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I acknowledge that I have read and understood the above information/requirements, and am a medically licensed professional, and will not resell any products ordered to other medical providers. IMPORTANT: By signing this consent form, you acknowledge that any products that the FDA has not provided pre market approval for are considered investigational and/or experimental and/or for research use, and as such do not have the ability to be legally advertised in any way that makes claims about their safety or outcomes. This disclaimer applies to both peptides and biologics as defined by the FDA, including but not limited to peptides/biologics created from amino acid sequences. Please consult your legal counsel for any questions regarding the governance of your state medical license as it pertains to the uses of such non-FDA approved biologics. Legal Disclaimer: Please note that Heal Well Corp is not a manufacturer nor a physician, and acts solely as a sales distributor of the products requested by the physician's office. Furthermore Heal Well Corp makes no recommendations on dosing or advice to patients. It is the sole responsibility of the physician's office to understand the regulatory status of any of the products ordered, and be familiar with the FDA guidelines, manufacturer and product guidelines, and other associated laws. Heal Well Corp shall be indemnified to the fullest extent permitted by law from any claims or action related to the physician's prescription of, recommendation of, or any other claim associated with the physician, its affiliates or its patients.
Signature
Date
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Month
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Day
Year
Date
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