Downloadable New Account Application:
Please download a PDF of our New Account Credit Application & Product Order Form. If your browser does not allow you to print the form, download and install the latest version of Adobe Reader. Prior to submission, please review our Terms and Conditions.

IMPORTANT:
It is required that each applicant do the following:
1) Fill out entire form for initial order
2) Scan and email [or] fax a copy of an AUTHORIZED SIGNATURE and DEA CERTIFICATE to complete your new account.

Fax to 800-341-6440 / Email to customerservice@clintpharmaceuticals.com

A Clint Customer Service Representative will contact you to verify your information, answer any questions you may have, and complete your new account process. You may also submit an order with our representative at that time.

Once your new account has been activated, a Personal Customer Number will be assigned to you. You will use your Customer Number with each future order.

Please contact us TOLL-FREE at 800.677.5022 if you have any questions regarding the New Account process.

Thank you.

Credit Application & Product Order Form    |    Adobe Reader