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Membership Profile
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Welcome to 4WebMed. Please answer the following questions so that we can process your membership application. It may take you a few minutes to complete, but the more detail and information you provide the better we can serve your needs. Thank you for your time.
Log-in:
*Login:
*Password: *Confirm:
*Remember: *Response:
Personal Information:
Relationship to Patient:
*Title:
*First Name: *Last Name:
*Address: Ste/Apt:
*City: *State: *Zip:
Company Name:
*Home Phone:
Work Phone: Ext:
Fax:
*Email:
Shipping Information:
Same as Personal Info
Remember this
address as:
Save to my address book
*Title: *Phone:
*First Name: *Last Name:
*Address: Ste/Apt:
*City: *State: *Zip:
*Location:
Company Name:
Billing Information:
Same as Shipping
Same as Personal info
Remember this
address as:
Save to my address book
*Title: *Phone:
*First Name: *Last Name:
*Address: Ste/Apt:
*City: *State: *Zip:
Company Name:
If you would like us to keep your credit card on file to make checking out easier, please fill in the number and expiration date below.
TypeCard #CVVExp.date
Patient Profile Questions:
The following questions are not required but highly recommended to make your search results more useful and focused.
Conditions: Select the condition(s) that best represent patient's health.
AIDS & Dysphagia
AIDS/HIV
Alzheimer's
Bowel/Digestive
Cancer
Cancer & Dysphagia
Cardiac/Heart
Constipation
Diabetes
Diabetes & Dysphagia
Dysphagia
Eating Disorders
Fitness & Weight Gain
Gastric Bypass
Geriatrics
Hepatic/Liver
Huntington's
Involuntary Weight Loss
Kidney/Renal
Lung/Pulmonary
Men's Health
Parkinson's
Pediatrics
Pressure Ulcers
Stroke
Surgery & Trauma
Weight Management
Women's Health
Wound Care
Other Condition(s):
Categories: Which of the following nutritional products are you interested in seeing? To view all product catagories do not make a selection.
Desserts & Snacks
Frozen Shake
Liquid & Powder Supplements
What other nutritional products is the patient currently using?
(product name only…no size or flavors):
Nutrition: Please check the item(s) that best represent what the patient currently needs in their diet.
Arginine - High
Biotin - High
Calcium - High
Calorie - High
Calorie - Low
Cholesterol - Low
Fat - Low
Fiber - High
Folic Acid - High
Glutamine - High
Iron - High
Lactose - Low
Phosphorus - High
Phosphorus - Low
Potassium - High
Potassium - Low
Protein - High
Protein - Low
Pureed Food
Sodium - Low
Sugar - Low
Thickened Bev - Honey
Thickened Bev - Nectar
Vitamin A - High
Vitamin B1 - High
Vitamin B12 - High
Vitamin B6 - High
Vitamin C - High
Vitamin D - High
Vitamin E - High
Vitamin K - High
Zinc - High
What other types of products and services would you like to see 4WebMed offer?
Cosmetic & Beauty Products Health Safe Home Cleaning Products Health Safe Travel Arrangements
Durable Medical Equipment Condition Specific Chat Rooms Personalized On-line Diary/Journal
Condition Specific Health News and Articles Personal Care/Hygiene Products (glucose test strips, wigs, adult diapers, bibs/aprons, air purifiers)
Optional Information Questions:
What other on-line health/medical or informational sites do you visit?
If you are purchasing other health or medical products on-line, what are you purchasing?
What health or medical related newspapes or magazines do you read or subscribe to?
What are the patient's physical limitations? Both normal activities and exercise...
Daily Activities:
Phisical Activities/Exercise:
How did you hear about 4WebMed?
Would you like to inform a friend about our services?
(Enter email or address)
Yes, I would like to receive electronic emails informing me about products, news and specials related to products that might be of interest to me.
Yes, I would like to add 4WebMed to my Favorite.


 
 
 
 


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