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Do You Currently Dispense AMERX Products? *

AMERX products include: AMERIGEL Advanced Skin and Wound Care, HELIX3 Bioactive Collagen, AMERX Wound Care Kits and Dressings, and EXTREMIT-EASE.

Yes

Do You Currently Purchase Your AMERX Products directly from AMERX Health Care? *

Yes

No. I currently purchase from a third-party distributor.

I need... *

Help logging into AMERXHC.com

Help purchasing products online

Information on the Turn-Key DME Wound Care Program or dispensing additional products

Distributor Name

Practice Contact Information

AMERX Account Number (if known)

Practice/Facility Name *

Physician Name *

Office Manager or Secondary Contact *

Street Address *

Suite, Apt., etc.

Optional

City *

State *

ZIP Code *

Phone *

Email *

Do You Have Satellite Locations? *

Yes

How Many Total Offices? *

Number of Physicians in Practice *

Number of Treatment Rooms *

How many diabetic patients do you see on a weekly basis? *

How many wound care patients do you treat on a weekly basis? *

How many matrixectomies (partial and total) do you perform on a weekly basis? *

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