1. Your details

Full name (required)

Choose a username (required)

Professional email (required)

Phone number (required)

2. Professional credentials

Professional credentials (required) MD DO NP PA PharmD Other

NPI number (required)

State license number (required)

State of licensure (required) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

DEA registration number (optional)

3. Your practice

Practice or clinic name (required)

Practice type (optional) Private Practice Hospital MedSpa Pharmacy Other

Practice website (optional)

Tax ID or EIN (required)

Does the NPI owner match the contact for this account? (required) Yes No

Practice street address (required)

Address line 2 (optional)

City (required)

Practice state (required) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP code (required)

Does your business have a reseller license? (optional) Yes No

Reseller permit number (optional)

4. Your referral

Sales representative (optional) No sales representative Paul Bakhtiar Bob Baravarian My representative is not listed I am not sure

Representative name if not listed (optional)

Referred by (optional)

5. Review and submit

I would also like to apply for an ABS Labs professional purchasing account.

Optional: your ABS Labs request is recorded with this application for separate professional-account review. ABS Health referral approval does not approve ABS Labs purchasing access.

I confirm that I am a licensed medical professional and that the professional and practice information provided is accurate.

Your application will be reviewed before referral access is approved. Please do not enter patient information. We will email you about your application status.