New Account Application


Qualified health practitioners are welcome to register through the Terra-Medica website, or download an application form PDF here. Once approved, an email will be sent to you with confirmation and your user login and password.

Internet resellers interested in selling online must have a valid Minimum Advertised Price Agreement in place. Please contact customer service to obtain a copy.

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Contact information

Billing and Mailing Information:

Shipping Address (if different from billing information)

Example: (020)-12345678

Referral contact service
* Credit Card Authorization

Practitioner Certification
Certification must be emailed as an attached jpg, gif, png or tiff file - or - faxed to us at 1-866-881-2888
(Other states - enter NA)

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*  Terms and Conditions - (please see the link provided at the bottom of this page, opens in a new window)