Provider Intake Form

Partner Registration

Submit your clinic, provider, billing, and verification details for Novagen account review. Approved accounts receive access to ordering tools after admin validation.

Contact Information

Primary contact for account approval and onboarding.

First Name *

Last Name *

Email *

Phone *

Business Information

Clinic identity and approved shipping location.

Business / Clinic Name *

Business / Clinic Address (Ship To Address) *

Provider Information

Used for NPI registry matching and internal account validation.

Provider Name (If Different Than Above)

NPI Number *

Upload Medical License *

PDF, JPG, or PNG. The file name is included with the intake request for admin review.

Upload File

Billing Information

Enter a card or ACH method for account review. Card CVV is never saved.

Billing Address (If Different Than Shipping Above)

Credit Card Profile

Name on Credit Card *

Card Number *

Expiration Date *

ACH Profile

Bank Name for ACH

Routing Number

Account Number

Account Type

Referral & Signature

Final intake details for admin review and account records.

Did Someone Refer You? *

Date *

Signature *

Draw signature area

Account Security

Credentials are used only after admin approval.

Password

Confirm Password

Additional Registration Details

NOVAGEN USA provides platform access only to verified healthcare providers, research institutions, and GPO's. Orders must be placed through authorized accounts and are intended exclusively for in-vitro research and analytical use. We do not sell directly to patients or individual consumers. All products are designated for professional use.

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