Medmate - SignUp

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Are you a Distributor/Supplier of medical related goods

Are you a Healthcare facility/provider/clinic or other provider of healthcare services to patients? (ie hospital, clinic, healthcare office)

Distributor/Supplier

Name of Organization

Address of Organization

Street no.

City

Postal Code / ZIP Code

Website of Company (Optional)

input URL of website

MDEL

if you do not have an MDEL, please indicate why not

First Name

Last Name

Title of User

Email Address

Phone number

where you can be reached at work

Choose your password

Confirm your Password

Healthcare facility/provider/clinic

Name of Facility

Address of Facility

Street no.

City

Country

Province/State

Postal Code / ZIP Code

Website of Facility (Optional)

input URL of website

First Name

Last Name

Title of User

Email Address

Phone number

where you can be reached at work

Choose your password

Confirm your Password

Subscription

A credit card is required to sign up for your free 3 month trial. You will not be charged until your 3 month trial has been completed, and you convert to a paid subscription. If you wish to cancel your subscription before the end of the 3 month trial, you can easily do so, and your credit card will not be charged. We require a credit card at the time of signing up for ease of transitioning to a paid subscription. Once your trial converts to a full subscription, you will receive a receipt, which you can use for a business expense reimbursement. We use Stripe as our payment processor. Stripe collects only the minimum amount of data required. If you have additional questions, please contact us!

Coupon Code Input coupon code: 3FORFREE (Subscription period will end 3 months after the date joined)

mr. Cardholder

•••• 0000

00/01

Company MedMate Inc
Subscription
($89.00 CAD regular price)
$00.00
GST/HST (0%) $00.00

You have to Pay

00 .00 CAD