Practitioner Account Application For DesBio

Information

Name*
First Name Last Name
Company Name
Date*
Date Format: MM slash DD slash YYYY
Office Phone*
Mobile Phone
Shipping Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Website
Your healthcare practice or specialty*
How did you hear about DesBio?*

Upload Certificate

Upload Certificate*
Drop files here or
Required: Please attach a healthcare practitioner certificate or other education documentation or certification that includes your name and fax to 801‐563‐7455 or email to orders@desbio.com. If you have questions please contact us.

Desbio Internet Sales Policy

Date*
Date Format: MM slash DD slash YYYY
Deseret Biologicals Internet Sales Policy Signature*
Deseret Biologicals Internet Sales Policy: I agree to abide by Deseret Biologicals’ policy on internet sales that no Deseret Biologicals product should be sold to the consumer without first providing a healthcare evaluation/consultation from a qualified healthcare professional. I will in no way allow customers to purchase Deseret Biologicals product from my website or any other website without first consulting directly with my patient/customer. I further agree that I will not resell any products that I purchase from Deseret Biologicals to anyone other than my own personal customers. I understand that I will be fully responsible for any and all costs that Deseret Biologicals incurs as a result of my breach of this agreement as well as a minimum payment of $5000 per infraction.

Desbio Return Policy

Date*
Date Format: MM slash DD slash YYYY
Deseret Biologicals Return Policy Signature*
Deseret Biologicals Return Policy: I understand that as an authorized distributor of Deseret Biologicals products I can, after calling Deseret Biologicals for authorization, return unopened product in good condition to Deseret Biologicals for credit on my account. I can use this merchandise credit to apply to future Deseret Biologicals purchases. I understand and agree that Deseret Biologicals does not issue refunds for product returns.

Healthcare Professional Certification

Date*
Date Format: MM slash DD slash YYYY
Healthcare Professional Certification Signature*
Healthcare Professional Certification: I understand that the products I purchase from Deseret Biologicals (the “Products”) are complex products whose effects could vary from patient to patient. I hereby acknowledge that, as a prescribing healthcare professional, I will prescribe the Products based solely on my own professional judgement, as opposed to reliance on any claim or statement made about the Products by Deseret Biologicals, its staff or representatives.

Product Advice Certification

Date*
Date Format: MM slash DD slash YYYY
Product Advice Certification Signature*
Product Advice Certification: I understand that Deseret Biologicals sells many types of Products including homeopathic products. I certify and acknowledge that by purchasing any Product from Deseret Biologicals that I am legally and lawfully able to provide advice to my clients/patients on the use of those Products and prescribe them based on my own professional judgment, and I am solely responsible for the determination of their usage. I agree to immediately notify Deseret Biologicals and to cease the purchase of any Products if I am unable to legally and lawfully comply with this statement.

Online Application