Apply for a Professional Account

Only licensed practitioners may open a professional account. Please submit the form below to apply for a professional account.
Name*
First Last
Practitioner Designation*
Company Name*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Ship to a different address?
Shipping Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CA Seller's Permit #
Phone*
Fax
Website
Patient referrals
- Please include me as a referral for patients looking for a practitioner in my area.
Referral Address*
- Billing Address
- Shipping Address
Will your office be placing orders for product to be drop-shipped directly to your patients?*
- Yes, please bill my office
- Yes, please bill the patient
- No
Will your office allow patients to order product directly from Beyond Balance?*
- Yes
- No
License Verification
Beyond Balance professional accounts are for licensed practitioners only.
How would you like to provide us with your license?*
- Upload copy of practitioner license
- Enter license number
Upload copy of practitioner license*
Practitioner License Number*
Account Access
Email Address*
Password*
Enter Password Confirm Password
How did you hear about us?
Subscribe to our mailing list
- Please send me updates about products, events and other Beyond Balance news.
USE OF BEYOND BALANCE, INC. PROPRIETARY INFORMATION (PHOTOS, PRODUCT INFORMATION, ETC.)*
- I have read and agree to the following: Beyond Balance, Inc. grants permission, revocable at any time and upon reasonable notice, to me and my company, to use the Beyond Balance formulas photographs and descriptions for use on their private-access company website. The Beyond Balance formula photographs and descriptions are to be used on the company website only for their patients. Beyond Balance, Inc. does not grant permission to use the photographs and descriptions for general public viewing, for resale or in any other manner.
Comments
This field is for validation purposes and should be left unchanged.

License Verification

Account Access

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