Licensed Practitioner Sign Up

Sign up (1 minute) 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 *

Office Phone (optional)

May Biogenetix email you messages and specials? *

Yes

May Biogenetix send you SMS notifications for orders, webinars, and specials? *

Yes

Get Included in the Biogenetix internal provider list for patient referrals *

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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Type of Practitioner/Practice (Other)

Practice Name (optional)

Address

Address 2

State

City

Postal Code

Practice Website (if applicable)

How did you hear about us? *

Select one

Biogenetix.com
Social Media
The Business Academy
Functional Medicine Shift
Injection University
Mediprenuers
Hands-On Diagnostics
Polish Your Business
Doctors Supplement Store
Niels Pedersen
Conference/Event
Magazine
Other
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How did you hear about us? (Other)

Common Conditions You Treat (optional)

Do you carry nutritional products?

Yes

Which nutritional products do you carry?

License Information

Providing Your License Information

I will email my license info later to [email protected]

I am ready to enter and upload my license info now

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.

Clinical Consulting Team Education & Recommendations Agreement

Type Your Name to Sign this Agreement: *

Terms of Use

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I agree to the following policies *

I understand and agree to the Terms of Use above.

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