New Account Form
Every licensed medical professional that will be purchasing 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.Shipments REQUIRE an appropriately licensed medical professional or authorized employee to sign for receipt of delivery If licensed medical professional or employee thereof does not sign at time of delivery, the preparations 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
*
First Name
Last Name
Sales Rep Email
*
example@example.com
Clinic Name
*
Clinic Contact Name
*
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
By submitting this application, I acknowledge that I have read and understood the above information/requirements, and am a medically licensed professional, and will not resell any preparations ordered to other medical providers.IMPORTANT: By signing this consent form, you acknowledge that any preparations that the FDA has not provided pre market approval for are considered investigational and/or experimental and/or for clinical/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 peptides as defined by the FDA, including but not limited to peptides 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 preparations.Legal Disclaimer: Please note that Heal Well Corp is not a manufacturer, medical practice nor a licensed medical practitioner, and acts solely as a sales facilitator of the preparations requested by the medical provider. Furthermore, Heal Well Corp makes no recommendations on dosing or preparation use. It is the sole responsibility of the medical provider’s office to understand the regulatory status of any of the preparations ordered, and be familiar with the FDA guidelines, state medical board regulations and other associated laws pertaining to preparations ordered. Heal Well Corp shall be indemnified to the fullest extent permitted by law from any claims or action related to the medical provider prescription of, recommendation of, or any other claim associated with the medical provider, its affiliates or its patients.Heal Well Corp is committed to protecting and respecting your privacy, and we only use your personal information to administer your account and to provide the preparations and services you requested from us. From time to time, we would like to contact you about our preparations and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:I agree to receive other communications from Heal Well CorpI authorize Heal Well Corp to charge the credit card and account information provided with the appropriate vendor for the products ordered. I understand a receipt for each payment will be sent to the email provided, and the charge will appear on my credit card or bank statement. I agree that no prior notification will be given when used to pay for my order placed.*You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.By clicking submit below, you consent to allow Heal Well Corp to store and process the personal information submitted above to provide you the content requested.
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Date
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