Provider Registration Form

Please fill out the following form to be entered into our system or to update your information. Once your information is submitted you will receive a confirmation email. After verifying your credentials* the SIBO ordering process will be sent to you in a follow-up email. Be sure to check your junk mail folders for an email from the SIBO Center. If you don’t receive an email 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.

Provider Name:

Professional License:

Other Credential:

License Number:

Expiration Date:

State licensed in:

NPI (US only):

DEA #:

Contact Info

Clinic Name:

Address:

City:

State:

Zip:

Office Phone:

Office Fax:

Email: