Hospital 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 *

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 *

Preferred Payment Method *

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

New Account set up