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6900 Kingspointe Pkwy, Orlando, FL 32819, US

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6900 Kingspointe Pkwy, Orlando, FL 32819, US

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Become a Registered XYMOGEN Practitioner

Apply Now!

XYMOGEN formulas can be obtained only through a licensed healthcare practitioner. If you would like additional information on how to partner with XYMOGEN, please fill out the form below to begin the application process.

*Denotes Required Field

Contact Info

*First name
*Last Name
*License #
*Zip or Postal Code

*Would you like to setup your account under the Business name or Qualifying Practitioner name?




NOTE: Please send a copy of your Current Business License and/or Resale Certificate to

BILLING ADDRESS (if different from above)

Contact Information

Will you be promoting XYMOGEN products through this website?


*Whom do we thank for referring you?

*Please name the three most common conditions you treat:

*Which brands do you currently carry in your practice? (Hold down Ctrl or Command on your keyboard to select multiple)

Any additional comments/requests?

Please note

All of the documents below are required before we can open your account. Please ensure that all required documents are signed, dated, and filled out in their entirety to avoid any unnecessary delays in our review process. If any of these documents are missing or incomplete, your wholesale account cannot be established. Please contact the New Accounts department if you have any questions.

  • New Account Application
  • Customer Protection Agreement
  • No Internet Sales Policy
  • Return Policy
  • Copy of current business license and/or resale certificate

Customer Protection Agreement

This Agreement is between the signed health care professional (“CUSTOMER”) and XYMOGEN. CUSTOMER shall not disclose XYMOGEN pricing on the Internet or supply XYMOGEN products to any re-sellers or retailers.
THIS XYMOGEN CUSTOMER PROTECTION AGREEMENT (“Agreement”) is made as of this day of , 20 (the “Effective Date”), by and between XYMOGEN, Inc. (“XYMOGEN”), an Illinois corporation, with its principal place of business located at 6900 Kingspointe Parkway, Orlando, FL 32819; and the health care professional, (“CUSTOMER”), with its principal place of business located at
In consideration of the mutual promises and covenants herein, XYMOGEN and CUSTOMER (“Parties”) do hereby agree as follows:
XYMOGEN and CUSTOMER (“Parties”) agree as follows:

Print Name:
Brian J. Blackburn, President/CEO

No Internet Sales Policy

*Customer Name:(Print)

Private Label Policy


Return Policy

*Printed Name:

Tax Exemption

State State Registration, Seller's Permit or ID Number of Purchaser State State Registration, Seller's Permit or ID Number of Purchaser

Yes, I am located in California and one of the following: MD, Osteopaths, Dentists or Podiatrist
Please continue filling out the California Tax Exemption below.



Patient-Direct Ordering

Patient Direct Ordering

*Are you interested in offering your patients ordering Privileges on


You can view the full W9 on the website.
1* Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above.
3* Check appropriate box for federal tax classification; check only one of the following seven boxes:
Individual/sole proprietor or single-member LLC

C Corporation
S Corporation


Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)

5* Address (number, street, and apt. or quite no.)
6* City, state, and ZIP code
7 List account number(s) here (optional)
Requester's name and address (optional)
*Taxpayer Identification Number (TIN)

Social Security Number
Employer Identification number
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certifications Instructions. You must not check item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Sign Here

*Signature of U.S. Person
Thank you for filling out your Application!

We will review your application and contact you if we have any questions or need any additional information. Should your application be approved, XYMOGEN will be able to setup your account for online ordering using the email address you provide.

If you have any questions or concerns, please do not hesitate to contact us. We are happy to help and look forward to working with you!

Your Tracking Number for this application is: . This number will also be emailed to you.

If you are participating at a XYMOGEN Event and have been given an Authorization Code to request an order, please enter the code below. This order will only be placed pending approval of your account.
Authorization Code:

If you prefer to download the form and submit by email (, fax (321-251-4674) or mail (6900 Kingspointe Parkway Orlando, Florida 32819), choose your location below.

United States Canada

If you need a W9 form, you can download that from the IRS by clicking here.

Upon submission of your application, you may be contacted for follow up inquires. If you have questions or concerns throughout the process, please do not hesitate to contact us. We are happy to help and look forward to working with you!

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*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.