Provider Sign Up Form

Provider Account Sign Up

Please complete the following to create your LaserCap provider account.

*required

First Name*
Last Name*
Title
Email*
Phone*
Name of practice/company
Website URL
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Shipping address same as billing?
- Yes
Shipping Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing email*

(for invoices and sales receipts)
Shipping email*

(for shipping confirmation and tracking info)
Billing preference (select one)*
By invoice - we will send you an electronically payable invoice for every order with option to pay via credit card or bank transfer. By Credit Card on file - you provide a credit card for use to keep on file and bill for approved orders.