Register

Healthcare practitioner accounts require verification and approval before practitioner pricing will be available. Once your account has been activated, you will receive an email communication advising you of your account status. If you need to place an order immediately, please click HERE to contact customer service.

Complete the form below or print the pdf and return to us.
Download pdf Account Application

Personal Information

First Name *

Last Name *

Email *

Website Address *

Facility or Business Name

Reseller Tax ID

Education

School *

Speciality *

Certification or Diploma *

Please upload your license/certificate or student ID. A picture of your certification is acceptable, take a picture with your phone and upload to our site.

Year Graduated

License Number

Address

Street Line 1*

Street Line 2

Country *

State*

City*

Postal Code*

Phone*

Communications

How did you hear of us? *

Referral Name / Event

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I agree to adhere to the terms and conditions as outlined in the ecoNugenics®/Clinical Synergy® Professional Formulas MAP Policy, which include selling Clinical Synergy® Professional Formulas products above the established MAP pricing and not listing these products for sale on any third party online retailers. Read and review the full Terms of Use and Privacy Policy.*

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About

Account Info

Contact Us

Clinical Synergy® Professional Formulas Santa Rosa, CA 95401 877.877.2362 info@clinicalsynergyformulas.com

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