Licensed Practitioner Sign Up

Submit your license/certification information (1 to 2 minutes) to be approved for your Biogenetix account and get access to the Learning Library, support from our Clinical Consulting Team, and ordering from our online store.

First Name *

Last Name *

Email *

Mobile Phone *

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Office Phone (optional)

Include me in the Biogenetix internal provider list for patient referrals *

Yes

It is okay for Biogenetix to send me SMS notifications for orders, webinars, and specials. *

Yes

It is okay for Biogenetix to send me email communications and specials. *

Yes

Practitioner/Practice Information

Type of Practitioner/Practice *

Select one

Functional Medicine Practitioner
Medical Doctor
Osteopaths
Registered Nurse
Nurse Practitioner
Chiropractor
Naturopath
Nutritionist
Physical Therapist
Health Coach
Midwife / Doula
Accupuncturist
Licensed Massage Therapist
Other
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Practice Name: (if applicable)

Address

Street Address *

City *

State *

Postal code *

Practice Website (if applicable)

How did you hear about us? *

Select One

Biogenetix.com
Advanced Medical Integrations
The Business Academy
Functional Medicine Shift
Mediprenuers
Hands-On Diagnostics
Social Media
Magazine
Other
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Other:

Common Conditions You Treat (optional)

Which nutritional products do you carry? (if applicable)

License Information

First Name on License/Certificate *

Last Name on License/Certificate *

State of Issued License/Certificate *

Expiration Date

Upload Picture or File of License/Certificate

Don't have it now? Email it to [email protected] when you can.

Terms and Conditions

To view the full Terms and Conditions click here.

I agree to the following policies *

I hereby acknowledge I understand and agree to the Terms and Conditions above.

I agree that I will not publicly publish pricing information for Biogenetix products anywhere online, and will not supply Biogenetix products to unauthorized re-sellers or retailers.