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Hospital Account Set Up
MEDOLAC LABORATORIES, A PUBLIC BENEFIT CORPORATION
New Account set up
Account Information
New accounts:
Complete and submit the form below and a Medolac Representative will contact you within 24 hrs, M-F.
Existing accounts:
Send us your completed Purchase Order: Fax: 503.305.8269 or Email:
sales@medolac.com
If you have questions or an urgent request, contact us at 1 (866) 599-7740
Account Type
*
New Account
Reactivation
Legal Business Name
*
DBA (if applicable)
*
Fed Tax ID Number
*
Billing Information
Contact Name
*
First
Last
Job Title
*
Email
*
Primary Phone Number
*
-
-
Extension
*
Secondary Phone Number
*
-
-
Extension
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Preferred Invoicing Method
*
Mail
Email
Fax
Preferred Payment Method
*
ACH Transfer
Credit Card
Terms
Shipping Info
My shipping address is same as billing
*
Yes
No
Destination Name
*
Contact Name
*
First
Last
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Accounts Payable Contact
Name
*
First
Last
Phone Number
*
-
-
Extension
*
Email
*
Fax Number
*
-
-
Purchasing Contact
Name
*
First
Last
Phone Number
*
-
-
Extension
*
Email
*
Fax
*
-
-
Clinical Contact
Name
*
First
Last
Phone Number
*
-
-
Extension
*
Email
*
Fax
*
-
-
Implicated Products Emergency Contact
Name
*
First
Last
Phone Number
*
-
-
Extension
*
Email
*
Fax
*
-
-
If you have questions or an urgent request, contact us at 1 (866) 599-7740
Submit
Home
About
Leadership
Message from CEO
Corporate Responsibility
Press Releases
Contact Us
CEO Blog
The Medolac Difference
Why Milk Banking
Safety & Quality
Donate Breast Milk
Products & Research
Publications
Order Online
Hospital Account Set Up