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Thank you for choosing Physicians Choice Buying Program.

Please complete the following enrollment profile. After submitting your profile you will be contacted within 24 hours by a Physicians Choice representative to complete the enrollment process.

Background Information:
Your Name:
Your Title :
Additional Contact Title:
Shipping Address:
Shipping Address:
Contact Phone:
Other Phone:
Fax:
E-mail:

Please tell us about your facility. Complete all that apply to you.
Facility Name: Facility Address:
	Profit
	Non-profit

Physician/Clinic:

Specialty
Number of Physicians
DEA Number

Please tell us your estimated monthly volume in each category that applies to your facility and if you have any interest in capital equipment purchases:
Medical-Surgical		Capital Equipment
Radiology		Capital Equipment
Lab		Capital Equipment
Pharmacy		Capital Equipment
Office		Capital Equipment
Other Comments: