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REGISTRATION & WHOLESALE DISCOUNT FORM

If you previously provided us with your address (and remember your password) select the left button. Or if you want to skip this, select the right button.
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Otherwise, fill out the form below to register. Only the items shown with asterisks are required.To apply for a wholesale discount, please fill out the additional questionnaire completely and then click the submit button. We will e-mail your discount percentage the next business day. This discount will be automatically calculated on all future orders. If you wish to place an order today, you will be given a one time 5% courtesy discount. This discount will not show up at checkout, but will appear on the invoice that comes with your order.
Mailing Name:
First:* M: Last:*
Mailing Address:
Company:
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City:*
State/Province:*
(US/Canada Only)
Zip/Postal Code:*
Country*
E-Mail and Phone:
E-MAIL*
PHONE*
Alternate:
FAX:*
Comments:
Check to apply for wholesale discount
Check to apply for state tax exemption
Check to be added to our e-mail list
Check to be added to our fax mailing list
Check to remember your login information and automatically sign in.
Reminder: If you are ordering today, please fax a copy of your state license and DEA license (if you have one) to 619-956-4290. If your business is in California and you wish to be tax exempt, fax us your resale certificate as well. Also, please make sure you look over the information on the “About Us” page.
Tell us about your facility (check all that apply):
Sole Practitioner
2-3 doctors
4 – 9 Doctors
10+ doctors
Private Practice
 HMO
Hospital Owned
Nursing Home
Hospital Pharmacy
Retail Pharmacy
 Occupational Health
Student Health Center
Psychiatry
What is your primary specialty? (Pick only one)
Approximately how much do you spend each month on Pharmaceuticals?
0 –$149.00
150.00-299.00
300.00 –749.00
750.00+
Approximately how much do you spend each month on Medical Supplies?
0 –$149.00
150.00-299.00
300.00 –749.00
750.00+
How did you hear about us?
Magazine
Fax Broadcast
Word of Mouth
Email
Web Surfing
 By Chance
Public Health
Snail Mail
Other
After registering, you must fill out and fax the Internet Drug Purchase & Credit Card Consent Form to us along with copies of your medical license and DEA (if you have one). Please click here to download a printable copy of the form. Fax: (619) 956-4290

By clicking the submit button, you are giving STAT Pharmaceuticals permission to send you additional communications about their products and services.
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