Request an MPS Client Account
Submit this form to request an MPS Client Account. We will verify the information and contact you when your account is ready.
|
|
Account No |
|
Account Mgr |
|
|
Primary Contact Info
|
Company* |
|
Contact* |
First
Last
|
Title |
(DMD, DDS, MD, RN, etc. 20 chars max)
|
Phone* |
(###-###-####)
Ext
|
Fax* |
(###-###-####)
No Fax
|
Email* |
|
Tax ID* |
(Tax ID or SSN) |
Payment |
(Additional payment information may be provided later)
|
|
Additional Contacts
If there are staff members who should receive specific notifications, please enter them here.
|
 |
Enter Other Contacts |
|
|
|
Shipping Info
|
Address* |
|
|
NOTE: Please include your suite number in the field above. |
Address 2 |
|
City* |
|
State* |
|
Zip Code* |
|
Billing Info
|
Use Shipping |
|
Address* |
|
|
NOTE: Please include your suite number in the field above. |
Address 2 |
|
City* |
|
State* |
|
Zip Code* |
|
DEA Certificate
|
No DEA |
|
Number* |
|
Expires* |
(mm/dd/yyyy) |
|
DEA Certificate name as it appears on the Certificate |
Name* |
|
State License
|
Number* |
|
Expires* |
(mm/dd/yyyy) |
|
State License name as it appears on the License |
Name* |
|
Primary Practice
Please indicate your primary practice type. We may use this to better tailor your experience on the website.
|
|
|
Website Passwords
Select a master password for access to both the MPS and CodeBlue websites.
This password gives you full access to formulary management, online ordering, package tracking, statements, purchase history,
and the CodeBlue Monitoring Service website.
|
|
|
Password* |
|
Confirm* |
|
|
|
Select a limited access password for just the CodeBlue Monitoring Service website. This can be used to give access to staff members who maintain your crash cart inventory. |
|
|
Password |
|
Confirm |
|
|
|
How did you hear about Medical Purchasing Solutions?
Please let us know if you were referred by a colleague, friend, sales rep, etc.
|
Source |
|
Referral Type |
|
Details |
|
Internal Notes
|
|
|
Required Documents
We will need copy of your State License to finalize the account.
If you plan to purchase controlled substances we will need a copy of your DEA Certificate as well.
Before we can send any products to Ohio locations, we need to have a current TDDD license on file.
Please email them to our Licensing Department at license@medicalpurchasingsolutions.com or fax them to (800) 351-0834.
|
Create AMP Account
|