Doctor Account RegistrationOnline Account Registration For Health Professionals"*" indicates required fieldsContact InfoUsername*Enter a username. (Min. 8 alphanumeric, lowercase chars. only).Password*Enter a password for your online account. (Min. 8 chars., incl. uppercase, lowercase, numbers). Enter Password Confirm Password Strength indicator Name* Mr./Ms./Dr Mr.Mrs.MissMs.Dr.Prof. First Last Facility/Business Name*Business Tax Id NumberBusiness Address* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Business Telephone*Mobile TelephoneEmail* Enter Email Confirm Email Website Account PaymentAccount Type*Enter an account typeSelect ...Doctor/PractitionerHealthcare StudentPayment Method*Enter a payment method.Select ...Credit CardAccount (Terms)Submit Credit Application*For payment terms, download Credit Application, fill, save and submit (upload) below.Accepted file types: pdf, Max. file size: 128 MB.EducationEducational InstitutionIf healthcare student, enter educational institution.Select...Canadian College of Naturopathic MedicineBoucher Institute of Naturopathic MedicineOtherSpeciality*Select ...Family MedicineHolistic MedicineHomeopathyNaturopathic MedicineOriental MedicineOtherCertification*Select ...Naturopathic DoctorMedical DoctorOriental Medicine DoctorTherapistHealthcare StudentOtherLicense NumberCommunicationHow did you hear about us?Select ...AdvertisementColleague/Friend/FamilyConference/SeminarInternetPatient/CustomerSales RepresentativeOtherLatest News Send me the latest on products, promotions and general newsPatient Referral ProgramYour patients purchase our products directly online using your AlphaScienceLabs referral code. Program not applicable to HealthCare Students. I wish to join AlphaScienceLabs' Patient Referral ProgramTerms of Use and Privacy Policy* I have read and agree to the Terms of Use* and Privacy Policy*.CommentsThis field is for validation purposes and should be left unchanged.
