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Professional Pricing


Registration

Doctors and Other Health Care Providers Only. This form will register you to gain access to an online catalog with professional pricing which you will be able to download and fill out. You must have a valid email address because the URL of the catalog will be sent to your email address. When completed please fax your request to us at 407.833.3833 or call us at 1.800.NEW FLEX

Why sign up? Click Here to see why professionals choose Synergy Therapeutic Systems.

* = mandatory

Name*:

 

Profession/Title*:

 

Clinic Name*:

 

Email*:

 

Street Address*:

 

City*:

 

State*:

 

Zip*:

 

Phone*:

 

Fax:

Licensed in States(s)*:

 

License Number(s)*:

 



 

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