Medifast Inc

Provider Agreement Form
Please fill out the Provider Agreement form below. Once the form is submitted, Medifast will send you a confirmation form informing you that your User ID and Password are activated. You will also receive a Customer Number (used when medical practitioners order Medifast products by phone).

* First Name:

* Last Name:

* License Number:

* License State:

* License Type:

* Practice Name:

* Contact Name:

* Street Address:

Suite:

* City:

* State:

* Zip:

* Phone Number:

Fax Number:

* Email Address:

Website:

* User ID:

* Password:

* Password (again):

If shipping address is different from above, please provide below.

Street Address:

Suite:

City:

State:

Zip:

* What is your medical specialty?

I understand that it is the responsibility of the Medical Practitioner and his/her practice to manage all elements for the Medifast program including ordering, receiving and distributing products.

* Medical Practitioner's Signature:

* Date:

Shop Online or Call 1.866.463.3432

Medifast very low calorie diets require physician supervision. Medifast recommends that you consult with your physician before staring any Medifast program.