Registration Form

Web Ordering System is for Canadian LTC Customers only with an existing account already set up with Futuremed (certain conditions apply). If you do not have an existing account, please contact our customer service department at (905) 761-0068.

Welcome to Futuremed's Web Order System. Now you can order Futuremed products at your convenience anytime day or night.

Our web order system allows you to place custom orders, view your account history or just browse our product offerings. Simply select the products you need and the order will be invoiced to your already existing account.

Place your order before 2pm and receive your goods the very next day.

Register today by filling out the customer activation form below or click here to download the file and fax to (905) 761 7889.

You will receive a confirmation e-mail activating your request within 3 business days.

WEB ORDERING - CUSTOMER ACTIVATION REQUEST

Fields marked (*) are required

Bill To:				Date:
				Customer Number:
Customer Name:	(*)
Address:	(*)
City:	(*)	Province	(*)	Postal Code:	(*)

Contact:	(*)		Phone Number:		(*)

Email:	(*)

Username and Password, cannot exceed 10 characters, no spaces.
Username: (*)
Password: (*)

Ship To:
Same as bill to ? yes: no: If No, Please complete Ship To, details below.
If more than 3, please complete details as listed on a separate sheet (click here) and submit by fax.

Name:				Ship to #
Address:				Suite #
City:		Province:		Postal Code:
Attention To:

Name:				Ship to #
Address:				Suite #
City:		Province:		Postal Code:
Attention To:


Name:				Ship To #
Address:				Suite #
City:		Province:		Postal Code:
Attention To:

© Futuremed Health Care Products L.P. 2010 - Toronto - Calgary - Vancouver
Tel: 905-761-0068 Fax: 905-761-9929 Toll Free: 1-800-387-7025