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Online Account Confirmation

Healthcare Practitioner

Please Use the Information Used for Your Current ProEnzol Account

Name*

First Name* Last Name*

Email Address*

Healthcare Practitoner Type*

ProEnzol Direct is Now Available to All Practitioners

ProEnzol Direct, our online supplement ordering program, was developed to make nutritional supplementation easier for you and more convenient for your patients while providing your practice with a source of income without any financial risk. Since your ProEnzol practitioner account application and customer agreement have already been approved, you automatically have access to ProEnzol Direct advantages and can immediately begin earning additional income for your practice.

With ProEnzol Direct, you have the ability to allow your patients to order supplements you recommend at proenzol.com and will earn income on these purchases. To create their own accounts, your patients will require a ProEnzol Direct code or affiliate link from you, their healthcare practitioner, authorizing their online purchases of ProEnzol supplements. Please remember that your ProEnzol Direct code and affiliate link may NOT be posted publicly on your personal or practice websites and should only be shared with your patients during consultations with you.

After approval of your online account registration, you will receive an email containing your unique ProEnzol Direct code and affiliate link to share with your patients as well as an explanation of the financial benefits available to you with ProEnzol Direct.

If you plan on using ProEnzol Direct and would like to receive income earned on your patients’ online purchases of ProEnzol supplements, you must upload a completed IRS W-9 form.

Download W-9 Form

Upload Your Completed IRS W-9 form.

Max. file size: 50 MB.

If you wish to display your practice/business contact information on your patients' dashboard, please fill out the following. This information will only be available to patients who have created an account using your specific ProEnzol Direct code.

Name of Practice/Business

Email Address

Phone Number

Please Read and Agree to the Following Policies:

BY SIGNING THIS AGREEMENT ELECTRONICALLY, YOU AGREE YOUR ELECTRONIC SIGNATURE IS THE LEGAL EQUIVALENT OF YOUR MANUAL/HANDWRITTEN SIGNATURE ON THIS AGREEMENT, AND YOU CONSENT TO THE LEGALLY BINDING TERMS OF USE, PRIVACY & SECURITY POLICY, PRACTITIONER EXCLUSIVE POLICY, AND INTERNET SALES POLICY. PLEASE E-SIGN YOUR SIGNATURE USING THE FOLLOWING FORMAT: FIRST NAME LAST NAME

Signature*

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