Provider Account Setup

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Clinic / Practice Information

Name of Clinic / Practice *

Address *

City *

State *

ZIP *

Phone *

Fax

Office Manager

Doctor / Provider *

Emergency Contact Phone *

Emergency Contact Email *

👤

Sales Associate

Sales Associate Name

Email

Phone

⚕️

Ordering Practitioner(s)

Practitioner 1

Full Name *

NPI # * (10 digits)

DEA #

Signature *

Sign here with mouse or finger

or

Practitioner 2 (optional)

Full Name

NPI # (10 digits)

DEA #

Signature

Sign here with mouse or finger

or

💰

Payment Method

Select your preferred payment method. You only need to complete one section.

🏦

ACH / Check

Pay via bank transfer — no convenience fee

💳

Credit Card

Visa, Mastercard, Discover, Amex — 2.99% fee applies

🏦

ACH / Check Authorization

This agreement governs ACH transactions initiated by Genova Biologix to charge the Company as a form of payment for purchase orders. Both parties agree to be bound by NACHA Operating Rules. This agreement provides authorization for individual or recurring transactions when individually authorized using the methods designated below. This agreement will remain in effect until company cancels in writing.

Account Setup:

New Setup Change / Modify Cancel / Stop

Bank Routing Number * (9 digits)

Checking Account Number *

Company Name on Account *

Financial Institution Name *

Bank Statement Address *

City *

State *

ZIP *

Authorization Methods (check all that apply):

Authorized Signature *

Sign here with mouse or finger

or

Date *

Name *

Title *

I certify that I am an authorized representative of the Company and have authority to enter into this Agreement. This authorization remains in effect until canceled in writing. Genova Biologix may charge $35.00 for each returned ACH transaction.

💳

Credit Card Authorization

This agreement provides authorization for individual or recurring transactions initiated by Genova Biologix for each purchase order authorized by Company. 2.99% convenience fee will be added to all credit card payments.

Name on Credit Card *

Billing Address *

City *

State *

ZIP *

Card Type *

Visa Mastercard Discover Amex

Card Number *

Expiration *

CVC * (3 digits)

Authorization Methods (check all that apply):

Authorized Signature *

Sign here with mouse or finger

or

Date *

Name *

Title *

I certify that I am the cardholder or authorized user. This authorization remains in effect until canceled in writing. In the event the credit card is rejected, Genova Biologix will attempt to reprocess or use another payment method on file.

Clinic / Practice Information

Sales Associate

Ordering Practitioner(s)

Payment Method

ACH / Check Authorization

Credit Card Authorization

Application Submitted!