My account | CBio

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User Type *

Legal Clinic Name *

Clinic Type

Medical Practice

Wellness Clinic

Research Facility

Other (Ex: Retailer)

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

For clinic use 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.

How did you hear about us?

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

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Provider Portal Access

C.BIO PEPTIDES

CLINIC APPLICATION & REGISTRATION FORM

Regenerative Medicine – Peptide Ordering Authorization