PRACTICE ENROLLMENT FORM

Date

Practice Name*

Phone*

Email*

Practice Address

City

State

Zip

Practice Main Contact Person*

Phone*

Email*

Provider Contact Information

Provider Name*

Phone *

Email*

Enrollment Fee: $250 (includes one SphenoCath device and access to training videos)

Quantity Discounts For Orders Over 10 Units

Estimated Order Quantity Per Month

Comments

Altera HealthTec Office Information

Altera HealthTec Representative: David Brown

Phone: (805) 686-1044

Email: DBrown@Rx2Live.com

Our Office Manager, Zully Cceres, will contact your office for Enrollment Fee and Product Orders. Her hours are 10-5 MDT M-F and her phone is (801) 766-2077

After your Enrollment you will receive your portal and training access.

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