Account Registration

License Holder's Information

If you have already registered with AJI Health website enter email address below and click verify button
 Email address:   
You are registering as a distributor for:


First Name:  
 Last Name:  
Company:
License/Certificate:
Other (Please specify all other titles) :
Contact Name:
Address1:   Address2:
City:   State:  
Zip code:  
Phone: Fax:
Payment Terms:    

Shipping Address

*This address is :
Address1:   Address2:
City:   State:  
Zip code:  
Is there another business address where doctor is located? If yes, please fill in below.
Address1: Address2:
City: State:
Zip code:

Questions

1. Would it be acceptable to have your name appear in the list "Find Healthcare Professionals" on our website?
2. How did you learn about our products?

(if "word-of-mouth" or Other is chosen, please explain)
3. Are you currently providing dietary supplements to patients?
4. Send me Email Promotions   
5. Would you like your webpage address to appear in "Find Healthcare Professionals" list

(if yes, please enter your website address below)

Registered User Terms & Conditions

  Terms and Conditions