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Personal Info

Name

Clinic / Business Info

Address Info

Billing Address
Is your shipping address the same as your billing address?

Physio Store Account Setup Info

Create a username for your account.
Invoices and correspondence will be sent to this email!

Payment Details

Will You Be Wanting to Purchase Using a Purchase Order?
If paying by Purchase Order, we may require additional information and will inform you if purchase orders are allowed within a few days. If approved, you will have have Net 30 terms. If you select No, you can pay normally through the checkout using the following options: Credit Card / Apple Pay / Google Pay / PayPal

Additional Info

Are you interested in having your clinic/business available on our site as a link for customers to visit your site?
We reserve the right to determine which clinics/businesses would be allowed on our site.
Are you interested in joing our affiliate program?
Join our affiliate program and make 10% on all sales directed to our store! Click here for more details.
How did you hear about us?