D & H Medical Supply

Contact Information
General Information
Yes No

If you dispense medication in your office please provide a copy of your state dispensing license. 

 ATTN: Nurse Practitioners

If your state requires a collaborating physician, you MUST submit your collaborating physician’s license and a legend drug and device authorization form also. 
Account Payment Method
Shipping Address Information
Billing Address Information
Membership Business Trade References

An invoice of your purchase is processed and sent with your order. A statement will be sent. ACH EOM debits will be initiated between the 10th and 15th of each month (if selected). Any NSF's will incur a $25.00 charge.

If NSF occurs twice your payment terms will be changed. Late fees are 1.5% of monthly past due balance.  

Company * Address Account # Telephone # Fax #
Authorized Officer Signature

I am an Authorized Officer of the Business with the authority to bind the Business listed above to the terms of this Agreement. The execution, delivery, and performance of this Agreement have been duly authorized. I will provide the evidence of such authorization upon request. I understand that the Business and I are individually and jointly liable for paying charges on the Account according to the Terms and Conditions set forth.  

Login Section

Subscribe To Our Newsletter

All Rights Reserved, © Dhmedsupply.com 2024.   Site By Web4budget