Provider Registration Form

Please fill out the following form to be registered in our system or to update your information. After verifying your credentials*, we will send you a verification email which includes our requisition form and ordering details. Be sure to check your junk mail folders for an email from the SIBO Center. If you don’t receive an email within 5 business days, contact the SIBO Lab.

*Please note that the SIBO kits we dispense contain Lactulose which is a legend drug regulated by the FDA. Kits can only be ordered by practitioners who have prescribing rights for legend drugs. This right is conferred through the practitioners’ state licensing board and is clearly defined in the scope of practice. If you are unsure of your prescribing rights contact your local licensing board before submitting this form.

Registration Type*
- New Registration
- Updated Provider Information
Contact Information
Provider Name*
Clinic Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Office Phone*
Office Fax
Email*
How did you hear about our lab?
Licensing Information
Professional Licence(s)*
Type (ND,etc.) Number Expiration Date State

Please enter your license type exactly as it is listed on your license. All four fields in each row are required.
NPI*
DEA Number If Applicable
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Type (ND,etc.)	Number	Expiration Date	State

Contact Information

Licensing Information