Customer Intake Form

If you are affiliated with a franchise, parent company, or a buying group, please tell us the company name:

Applicants Registered Company or DBA. This is the name your account will be under. If you do not have a company name, type your name: *

How did you hear about Fountain Medical Supplies?

Industry:

Have you been working with a sales rep? If yes, state their name:

Contact Name: *

Contact Phone: *

Email Address: *

Billing Street Address: *

Suite/Apt Number:

Zip: *

State: *

City: *

Billing Phone: *

Is Shipping address the same as Billing address?

Shipping Street Address: *

Suite/Apt Number:

Zip: *

State: *

City: *

Shipping Phone: *

Medical Director:

Name:

NPI #: