Provider Application · Elite Cell Source

01

Account type

Tell us who is registering.

DoctorClinicClinic Staff

02

Your details

The person creating this account.

First name *

Last name *

Direct phone

Clinical Library focus areas

Choose the areas you want surfaced first in your Clinical Library. Optional — you can change these anytime from your account.

03

Your credentials

Used to verify your eligibility to order.

NPI number *

DEA number

State license number *

License state *

Expiration

Specialty

Auto-filled from the NPI registry; edit if needed.

04

Practice information

Your clinic or practice details.

Practice / clinic name *

Office address *

Suite / unit

City *

State *

ZIP *

Office phone *

Office email *

Primary contact person

05

Account credentials

You'll use these to sign in.

Email *

Password *

Confirm password *

06

License documentation

Optional now — we may request it during review.

Upload license (PDF, JPG, or PNG · max 15 MB)

07

Attestation & Agreement

I confirm that the information provided is accurate, that I am a licensed provider (or authorized to register on behalf of one), and that I am authorized to place patient-specific prescription orders. I have read and agree to the Privacy Policy.On behalf of the Practice, and as a person authorized to bind it, I have read and agree to the Elite Cell Source Provider Agreement. I understand my acceptance is an electronic signature, valid under Fla. Stat. § 668.50, recorded with my name, the date and time, and my IP address.