Southlake Medical Supplies, Inc.

We follow HIPAA guidelines and keep your personal information strictly confidential. Once you have registered with us, we will contact you directly by phone to discuss your specific needs and qualification for Medicare or Medicaid reimbursements. If you are under the age of 18 years, please ask your parent or legal guardian to contact us directly. For more information please refer to Legal & Privacy Policy.

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Contact Information
First Name*
Middle Name*
Last Name*
Email*
Street Address*
City*
State*	At present, we only serve the 48 contiguous states and not Alaska or Hawaii
ZIP*
Phone*
FAX
Account Information
Username*	Username must be between 6-12 characters
Password*	Password must be between 6-12 characters
Re-type Password*
Check products interested in

If interested in other product, please describe below:
Regulatory
DEA Number*	If none enter "None". Required only for physicians.
Terms and Conditions
* I VERIFY THAT I HAVE READ AND AGREE TO THE Legal & Privacy Policy