November 18, 2017

Sign up for Account

 

New Practitioner Account Form

Thank you for choosing Socialvite. Please complete this form. We will be in contact shortly if it is necessary to fax a copy of your license.
  • Provider “Customer” Name
  • Clinic/Pharmacy Name
  • Contact Person
  • Choose which professional degree you have.
  • List each postgraduate school you attended.
  • List the license number and state issued for any professional degree you listed above. If a student, please list school and expected graduation date.
  • Email is required to receive purchase receipts and donation updates.
  • Main telephone number.
  • Optional seconadary telephone number.
  • Fax line number.
  • Shipping address where product orders will be sent.
  • Name of person in charge on paying bills.
  • Required approval of Socialvite Internet Policy.
    If you answered yes, please complete a Certificate of Exemption Form. Please fill out and fax to: 866-462-6742. http://www.revenue.state.mn.us/Forms_and_Instructions/st3.pdf