Create Your Affiliate Profile

If you have your own clinic website, this is a GREAT OPPORTUNITY to add an online store to your website to refer your patients, while generating additional revenue. Need to suggest to you patients that they need a brace? Why not just tell them to order it by clicking on the banner on your website instead of sending them elsewhere.

Whether you have a clinic website or not, you can incorporate PatientSupplies.com into your practice. We will provide you with an Online Store banner ad for you to add to your website as well as email to patients and other potential customers.

Once you register, you will receive complete details on how to access your custom banner ad and details on how to manage your partner account.

Profile details

Personal information Title * Mr. Mrs. Ms. Dr. First name * Last name * Company   SSN   Mailing address Address * Address (line 2)   City * State * Other US: Alabama US: Alaska US: Arizona US: Arkansas US: California US: Colorado US: Connecticut US: Delaware US: District of Columbia US: Florida US: Georgia US: Guam US: Hawaii US: Idaho US: Illinois US: Indiana US: Iowa US: Kansas US: Kentucky US: Louisiana US: Maine US: Maryland US: Massachusetts US: Michigan US: Minnesota US: Mississippi US: Missouri US: Montana US: Nebraska US: Nevada US: New Hampshire US: New Jersey US: New Mexico US: New York US: North Carolina US: North Dakota US: Ohio US: Oklahoma US: Oregon US: Pennsylvania US: Puerto Rico US: Rhode Island US: South Carolina US: South Dakota US: Tennessee US: Texas US: Utah US: Vermont US: Virgin Islands US: Virginia US: Washington US: West Virginia US: Wisconsin US: Wyoming Country * Canada Mexico Puerto Rico United States United States Minor Outlying Islands United States Virgin Islands Zip/Postal code * Contact information Phone * Email * Make sure you enter a valid email address because the store will send you notifications to this address. Fax   Web site   Username & Password Username * Password * Confirm password * Type the characters you see in the picture: Clicking "Submit" you agree with our"Terms & Conditions"   Submit All information you provide to us will be kept confidential. We will never sell, exchange or market it in any way.