Online Account Registration 2021

ACCOUNT REGISTRATION FORM

Please provide the following information to open your Healthcare Practitioner Account.
ACCOUNT CATEGORY: *

INDIVIDUAL (Individual Prescriber) CORPORATE (Multiple Prescribers)
Name | Company Representative: *

First Name Last Name
TIN *
Specialty Services (of Practice): *
Professional | Services Specialty
E-mail: *
[email protected]
Telephone No: *
(Type NA if not applicable.)
Mobile No: *
(Type NA if not applicable.)
Authorized Person To Facilitate Orders: *
Position:

Assisting Staff (Nurse, Secretary, the like) Purchasing Department
Preferred Contact Method:

Mobile Landline Email
Business Hours: *
For deliveries and visits.
Affiliate Doctors in Practice: *
Type NA, if not applicable.
Address: *

Street Address

Street Address Line 2

City

Postal / Zip Code Country
Other Account Information

Tick as applicable:
Would you want to join the online directory for Inquiries online? *

YES, include me in your online directory. NO, exclude me in your online directory.
Opt for emailed newsletters to receive the latest product information, pricing updates, policy changes and event announcements. *

YES, sign me up for newsletters. NO, do not sign me up for newsletters.
How did you hear about us? *

Facebook Google Search Personal Referral Medical Association Information
Assigned Account Specialist *
REQUIREMENTS FOR ACCOUNT ACTIVATION:
1. Accomplished Account Registration Form
2. Valid PRC License ID: Copy
3. For Corporate Accounts only: Copy of valid Business Permit
Requirements for upload here:

Browse Files
In PDF, JEPG Cancel of

TERMS AND CONDITIONS

a) Supplement Orders
1. Purchase orders or requests shall be entertained only via EMAIL to: [email protected]
2. All orders shall be acknowledged prior to delivery.
b) Delivery
1. Orders are shipped for delivery within 48 hours from order acknowledgement and receipt of payment.
2. Free delivery for orders above Php 5,000.00 within greater Metro Manila.
c) Returns
1. Returns are accepted 7 days from delivery date, upon written request and the presentation of merchandise in good condition.
d) Payment
1. Cash
2. Name checks to Spectrum Innovations
3. Bank deposits | Telegraphic Transfer | Online Transfer
BDO Makati-Ayala Avenue (Locsin Building)

Acct Name: Spectrum Innovations Inc.

Acct No.: (Checking Account) 005-318-033-760

UNIONBANK Greenbelt

Acct Name: Spectrum Innovations Inc.

Acct No.: (Checking Account) 000-560-036-371

III. PRIVACY POLICY

Please see link here.

IV. CONFORME
- - - *

I have read and accept Spectrum Innovations' Account Registration Terms and Conditions.
Signature *

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