Complete Your Registration Items marked with an "*" are required. First Name *: Last Name *: SLN * Professional Designation *: Select Designation APRNDOMDNPPAOther Specialty *: Select Specialty Family Medicine Other NPI * Other Designation *: State of License *: Select State AAAEALABAMAALASKAAPARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING Other Specialty *: Add Your Shipping Address InformationEnter your Zip Code to find matching City and State. Please note that P.O. Box addresses are not accepted. Practice Name: Shipping Address 1 * : Shipping Address 2: Phone *: Zip Code *: State *: City * P.O.Box addresses are not acceptable. Email Address *: Confirm Email Address *: Password *: Password creation requirements: Passwords must be at least 8 characters long. Passwords are case sensitive. Passwords must contain at least three of the following: Upper Case Character, Lower Case Character, and Numeric Value. Close Confirm Password *: Password Hints: Passwords must be at least 8 characters long. Passwords are case sensitive. Passwords must contain at least three of the following: Upper Case Character, Lower Case Character, Numeric Value, or Special Character. Please create a unique PIN number. This will be used as your electronic signature for your order. PIN *: PIN Information: Your PIN must be 4 digits and not contain sequential or repeating values, such as 1234, 4321, or 1111, etc. Keep a record of it in a safe place. This PIN will be associated with your account for all future sample requests placed through this site and will serve as your signature. Close Confirm PIN *: PIN Hints: Your PIN must be 4 digits and not contain sequential or repeating values, such as 1234, 4321, or 1111, etc. Keep a record of it in a safe place. This PIN will be associated with your account for all future sample requests placed through this site and will serve as your signature. Security Question 1 *: Select Question What is the first concert you attended?Who was your childhood best friend?What street did you grow up on?What was your first pet's name?What was your first car? Security Question 2 *: Select Question What was your first job?What is your grandmother's first name?Where did you go the first time you flew in an airplane?What is the name of your elementary school?What city were you born in? I acknowledge that this registration creates an electronic signature. You are required to create a password and PIN to order samples through this portal. I understand and agree to receiving system generated, transactional emails related to my activity directly on this site. My signature and PIN certifies that I am a licensed practitioner and have requested the above identified samples. If I am a Nurse Practitioner or Physician Assistant, I certify that I am authorized and eligible in the state within which I am currently practicing, to request and receive these samples and that my supervising Physician has delegated the authority to do so. Furthermore, I have requested these samples for the medical needs of my patients and I acknowledge that they are not for sale, resale, trade, barter, to be returned for credit or for third party reimbursement. I acknowledge that this registration creates an electronic signature. You are required to create a password and PIN to order samples through this portal. I understand and agree to receiving system generated, transactional emails related to my activity directly on this site. My signature and PIN certifies that I am a licensed practitioner and have requested the above identified samples. If I am a Nurse Practitioner or Physician Assistant, I certify that I am authorized and eligible in the state within which I am currently practicing, to request and receive these samples and that my supervising Physician has delegated the authority to do so. Furthermore, I have requested these samples for the medical needs of my patients and I acknowledge that they are not for sale, resale, trade, barter, to be returned for credit or for third party reimbursement. Cancel Submit