Account Set-Up

Company Information
Company Information
Company Name*
Physical Address*
Street Address Address Line 2 City State ZIP Code
Is the Billing Address the Same as the Physical Address.*
- Yes
- No
Please note that your company must be pre-approved prior to being allowed to charge on your account. Payment will be required at the time of service until your company is pre-approved for charging. You may arrange payment over the phone, pre-pay online at our website or make other payment arrangements prior to the time of service.
Billing Address
Street Address Address Line 2 City State ZIP Code
How many years has your company been in business?*
Please enter a number greater than or equal to 1.
How many employees does your company have?*
Please enter a number greater than or equal to 1.
Website

Master and Sub-account location upload
Accepted file types: xls, xslx, Max. file size: 20 MB.
If you have more than 10 locations, please Download and Complete our Multiple Location Spreadsheet. Upload here or eMail the completed form to (Info@MedScreensInc.com).
Sub-Location #1
Sub-Location #1 Contact
First Last
Sub-Location #1 Phone
Sub-Location #1 Fax
Sub-Location #1 eMail
Sub-Location #1 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #2
Sub-Location #2 Contact
First Last
Sub-Location #2 Phone
Sub-Location #2 Fax
Sub-Location #2 eMail
Sub-Location #2 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #3
Sub-Location #3 Contact
First Last
Sub-Location #3 Phone
Sub-Location #3 Fax
Sub-Location #3 eMail
Sub-Location #3 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #4
Sub-Location #4 Contact
First Last
Sub-Location #4 Phone
Sub-Location #4 Fax
Sub-Location #4 eMail
Sub-Location #4 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #5
Sub-Location #5 Contact
First Last
Sub-Location #5 Phone
Sub-Location #5 Fax
Sub-Location #5 eMail
Sub-Location #5 Physical Address
Street Address Address Line 2 City State ZIP Code
Do you have more locations?
- Yes
- No

Sub-Location #6
Sub-Location #6 Contact
First Last
Sub-Location #6 Phone
Sub-Location #6 Fax
Sub-Location #6 eMail
Sub-Location #6 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #7
Sub-Location #7 Contact
First Last
Sub-Location #7 Phone
Sub-Location #7 Fax
Sub-Location #7 eMail
Sub-Location #7 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #8
Sub-Location #8 Contact
First Last
Sub-Location #8 Phone
Sub-Location #8 Fax
Sub-Location #8 eMail
Sub-Location #8 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #9
Sub-Location #9 Contact
First Last
Sub-Location #9 Phone
Sub-Location #9 Fax
Sub-Location #9 eMail
Sub-Location #9 Physical Address
Street Address Address Line 2 City State ZIP Code
Sub-Location #10
Sub-Location #10 Contact
First Last
Sub-Location #10 Phone
Sub-Location #10 Fax
Sub-Location #10 eMail
Sub-Location #10 Physical Address
Street Address Address Line 2 City State ZIP Code

Company Information