Practitioner Registration

Thank you for applying for a Pacific BioLogic account. Our products are sold only to health care providers or by prearranged authorization. Once we evaluate and approve your application, you will receive an email at the address submitted with your application and you may begin ordering. If you do not receive an email authorizing you, please check your "spam" or "junk" email folders, or call us at 800-869-8783 to verify that your request was received. This approval may take up to one business day.

You may arrange for patients to order products directly from this site using an authorized account for your patient.

Fill out the form below to apply for authorization to purchase Pacific BioLogic Products.

First Name: *

Last Name: *

Specialty Type (MD, etc.): *

Company:

Address 1: *

Address 2:

City: *

State:

Zip / Postal Code:

Country: *

Phone Number: *

Fax:

Email Address: *

Password: *

How Did you hear about us?:

Do you agree to the terms of use?: *

Yes