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1-800-891-3452
1-800-891-3452
Home
About Us
Coded Products
ProText
AmnioText
Non-Coded Products
CryoText
SecreText
Product Compliance
News
Publications
FAQ
Contact
1-800-891-3452
Account Setup
Account Information
Clinic or Practice Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
Fax Number
Physician Name
Name
First
Last
Physician NPI
Billing Address
Same as Account Information
Same as Account Information
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Office
Name (Primary Contact)
Title
Email Address (Primary Contact) *
*
Phone Number (Primary Contact)
Secondary Office
Name (Secondary Contact)
Title
Email Address (Secondary Contact)
Phone Number (Secondary Contact)
Distributor
Distributor Name
Distributor Email
Distributor Phone
Sales Representative
Sales Rep Name
Sales Rep Email
Sales Rep Phone