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 *

By clicking SUBMIT you consent to receiving SMS messages. Messages and Data rates may apply. Message frequency will vary. Reply Help to get more assistance. Reply Stop to Opt-out of messaging

Office Phone (optional)

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

Yes

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

Yes

Include me in the Biogenetix internal provider list for patient referrals

Yes

Select The Type of Practicioner/Practice *

Practice Name: (if applicable)

Address

Street Address *

City *

State *

Postal code *

How did you hear about us?

Practice Website: (if applicable)

Common Conditions You Treat (optional)

Which nutritional products do you carry? (optional)

Please select how you heard about Biogenetix? *

Other:

Name listed on License/Certificate

State of Issued License/Certificate *

Expiration Date

Please attach a copy of current practitioner's license

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

Terms & 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.