MedXpress Registry New Account Registration

Please enter the contact information for your organization.

* indicates a required field.

Practice Name:*

Vendor:*

First Name:*

Last Name:*

Address:*

Address 2:

City:*

State:*

Zip:*

Email:*

To access your account you will need your email address and password. Please use your practice email, not personal or private. This account will be accessed by all providers in your practice.

Confirm Email:*

Password:*

Please choose a password between 8 and 20 characters. You must use both upper and lower case letters, at least one number and at least one special character.

Confirm Password:*

Contact Phone:*

Phone Ext:

Preferred Contact Method:

Preferred Contact Time:

Authorization Code:*

Please make up a 10 character code so we may ask you for it to verify your identity. Do not misplace this code. This has nothing to do with your claims or reports.

Referred By:

If you were referred to MedXpress by someone, please put their name and/or phone number below so that we may thank them

Include me in your company mailing list.

I have read and accepted the MedXpress Registry terms of service and use