Register Now

[vc_row css=”.vc_custom_1636379560779{margin-bottom: 50px !important;}”][vc_column width=”1/12″][/vc_column][vc_column width=”10/12″][vc_custom_heading text=”Register Now” font_container=”tag:h2|text_align:center” use_theme_fonts=”yes” el_class=”title-contact”][vc_custom_heading text=”Practice-Provider Enrollment Form” font_container=”tag:h4|text_align:center” use_theme_fonts=”yes” el_class=”title-contact”]

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Email

This field is for validation purposes and should be left unchanged.

Practice Name*

This is going to be the account username and can not be changed.

Address*

Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Office Contact*

First Last

Phone*

Email*

Password

Enter Password Confirm Password

Referred by*

Please SelectBayer RepresentativeNexplanon RepresentativeParagard RepresentativeOther

Name of Nexplanon Certified Trained Clinician*

Providers List*

Please provide provider list. You can add multiple providers clicking the plus icon.

Provider Name

NPI

State License #

 

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Consent*

I have read and agree with the Terms of Usage, Privacy Policy*

Practice Representative Signature*

I understand that MyIUDSupply may contact the referred patient by telephone or telemedicine for the following reasons: verification and coordination of benefits, confirmation of IUD ordered and consent, review of clinical information including safety and educational instructions.

[/vc_column_text][vc_custom_heading text=”Questions” use_theme_fonts=”yes” css=”.vc_custom_1726221988905{padding-top: 50px !important;}” el_class=”title-contact”][vc_column_text css=””]

Albert LoBuglio

Phone: (404) 550-8246
Email: alobuglio.myiud@gmail.com

[/vc_column_text][/vc_column][vc_column width=”1/12″][/vc_column][/vc_row][vc_row full_width=”stretch_row” disable_element=”yes” css=”.vc_custom_1600423085418{margin-top: 20px !important;margin-bottom: -20px !important;padding-bottom: 35px !important;background-color: #e54c34 !important;}”][vc_column][vc_column_text][contact-form-7 id=”7203″][vc_custom_heading text=”***Please email copies of the Medical License of each Provider to” font_container=”tag:h3|text_align:center|color:%23ffffff” use_theme_fonts=”yes” el_class=”title-contact”][vc_custom_heading text=”MyIUDsupply.register@gmail.com” font_container=”tag:h2|text_align:center|color:%23ffffff” use_theme_fonts=”yes” el_class=”title-contact” css=”.vc_custom_1599764622339{margin-top: 25px !important;margin-bottom: 25px !important;}” link=”url:mailto%3Amyiud.supply%40gmail.com|||”][vc_custom_heading text=”Once submitted and approved you will an email with your username and password” font_container=”tag:h4|text_align:center|color:%23ffffff” use_theme_fonts=”yes” el_class=”title-contact” css=”.vc_custom_1599114616444{margin-top: 25px !important;margin-bottom: 25px !important;}”][/vc_column_text][/vc_column][/vc_row]