Provider Intake

NovaForm BioHealth provides platform access exclusively to verified healthcare providers, research institutions, and group purchasing organizations (GPOs) for institutional and laboratory use. All product orders must originate from authorized accounts and are supplied strictly for in-vitro research and analytical purposes.

What happens next?

After submitting, our team will review your application within 5-10 business days. Once approved, you'll receive an email with instructions to set up your account password and begin ordering.

Contact Information

Primary contact for this account.

First Name *

Last Name *

Suffix

Email *

Phone *

Business Details

Tell us about your business and main identifiers.

Company Name *

Website

Tax ID / EIN *

NPI Number *

Does the owner of the NPI number match the contact for this account? *

Reseller Information

Enter your reseller's license details if applicable.

Does your business have a reseller's license *

Business Address

Business's primary address.

Business Address *

Suite / Unit

City *

State *

Zip Code *

Business Credentials

Optional at this stage. Clinics may upload a business permit; individual providers may upload a license or valid ID. Required later to complete your application.

Upload Proof of Business or Professional License

Drop files here or browse

Referral and Notes

Additional information to help us process your application.

Referred by someone else? Let us know!

Additional Notes or Comments

I agree to the Terms of Service and Privacy Policy. *I acknowledge that all products sold by NovaForm BioHealth are for Research Use Only (RUO) and are not intended for human or veterinary use, food additives, drug, household, or cosmetic use. I confirm that I will only use these products for legitimate research purposes in compliance with all applicable laws and regulations. *

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