Account Setup Form

Company Name:*

Type Of Business:

President/Owner:*

Office Manager:*

Contact For Order Placement:*

Phone:*

Area Code

-

Phone Number

Fax:

Area Code

-

Phone Number

Cell:

Area Code

-

Phone Number

E-mail:*

Billing Address:*

Street AddressCityStateZip Code

Shipping Address:*

Street AddressCityStatePostal / Zip Code

Tax Exempt?*

Yes

No

If YES to Tax Exempt, Please attach your tax exempt form:

Upload Tax Exempt Form:

Please upload a copy of the Doctor or Medical Director's License:

Standard terms are Net 30. By submitting this form below, you are acknowledging that you are an authorized representative of the company listed in the form above.

Account Setup Form

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Cities We Serve

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Lifecare Medical Supply

113 Production Dr,
Slidell, LA 70460

985-649-3019

Account Setup Form

Bottom Menu

Cities We Serve

Contact Us

Lifecare Medical Supply

113 Production Dr, Slidell, LA 70460

985-649-3019

113 Production Dr,
Slidell, LA 70460