My account | CBio

E-mail Address Required A link to set a new password will be sent to your email address.

User Type *

Legal Clinic Name *

Clinic Type *

Medical Practice

Wellness Clinic

Research Facility

Other

Please Specify Clinic Type (Others)

Tax ID/EIN Number

Website

NPI Number *

State of Business Formation *

First Name *

Last Name *

Title / Role *

Phone Number *

Does the Owner of the NPI number match the contact for this account? *

Yes

If No, I acknowledge I will be required provide written approval from the owner of the NPI number prior to the account being approved *

Street Address *

Town / City *

Country and State *

Postcode / ZIP *

Medical Director / Supervising Provider Name *

License Type & License Number *

State(s) Licensed In *

Please initial EACH statement below *

Products ordered are for clinic use only

Clinic acknowledges products may be designated Research Use Only (RUO)

Clinic agrees to comply with all applicable federal, state, and local laws

Manufacturer reserves the right to approve, deny, or revoke ordering privileges at its discretion

Authorized Representative Name *

Title *

Date *

Please agree to our terms & conditions

I agree to the Terms & Conditions.

Referral Code (optional) If you have a referral code from your C.bio sales contact, enter it here.

Your personal data will be used to support your experience throughout this website, to manage access to your account, and for other purposes described in our privacy policy.

Provider Portal Access

C.BIO PEPTIDES

CLINIC APPLICATION & REGISTRATION FORM

Regenerative Medicine – Peptide Ordering Authorization