CMS Healthcare Professional Registration

Healthcare Professional Registration *

* To see professional list prices please complete this form.
Company Name (Doctor's Name)
Required FieldFirst Name (Your First Name)
Required FieldLast Name (Your Last Name)
DEA Practitioner's License 
Required FieldEmail (For Logging In)
Required FieldPhone Number 
Fax 
Required FieldAddress line 1 
Address line 2 
Required FieldCity 
State 
Required FieldZip/Postal Code 
Required FieldCountry 
I'd Like to Receive Fax Specials 


Once completed the password will be emailed to you within the next 2 hours during business days.
You can reset it later once you log in.
Please call us at 866-554-3734 to discuss additional pricing programs that you may be eligible for.
We appreciate your business!

Note: No registration is required to place an order or to enter online checkout.
Registration is only required for a discount or to purchase restricted items.