Professional Account Application

1. Your details
2. Company details
3. Sales Rep & review

Your details

Enter your name and contact information.

First name

Last name

Email address

Phone

Create password

Use at least 12 characters. You will use this password after your account is approved.

Company details

Enter your company, NPI and reseller information.

Company name

Website (optional)

Tax ID / EIN

NPI number

State license number (optional)

DEA registration number (optional)

Does the owner of the NPI number match the contact for this account? * Yes No

Does your business have a reseller’s license? Yes No

Upload reseller’s certificate (optional)

Reseller’s permit number (optional)

Supported file types: JPG, JPEG, PNG, TXT, PDF, DOC, DOCX. Maximum 2 MB. Documents are stored privately for application review.

Practice address

Who is your Sales Rep?

If a sales rep introduced you to ABS Labs, select them below. If they are not listed, choose “My rep isn’t listed” and type their name. This is optional.

Assigned Sales Rep (optional)

Type your Sales Rep’s name

Referred by (optional)

I confirm that the information I provided is accurate.

Your application is reviewed manually. Submitting this form does not approve your account.

Your details

Company details

Practice address

Who is your Sales Rep?

Review your application