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New Clinic Online Registration

Company Name: *

First Name: *

Last Name: *

Email Address: *

Phone: *

Ext.:

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City: *

State: *

Zip/Postal Code: *

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Please fill this form out if you currently have a regular Victor Medical Account and need a Victor Medical Online Account. If you do not have a regular Victor Medical Account you will need to set that up with our Accounting Department before we can issue you an online account. Please call 800-888-8908 and ask for Camaron. Thank you!

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