Practitioner Registration

Doctor Sign-up

If you are human, leave this field blank.

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 2

City *

State *

Zip *

Discipline *

Facility or Business Name *

School

Speciality

EIN / SSN

Used for tax reporting on doctor income earned when patients order directly through Tesseract using their Practitioner's Code.

Certification

Practitioner License / Certificate

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Maximum upload size: 10.49MB

Ex: Clear scan, photo, or digital copy

Practitioner License / Certificate Number *

Accelerates account approval

Will you be reselling Tesseract products to your patients? *

Yes

Reseller Tax ID

State Issued Resell Tax Certificate

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Maximum upload size: 10.49MB

I would like to participate in future product trials by providing feedback on patient results on new or pre-release products.

Yes

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