New Credit Application
*Required Field

Thank you for your interest in establishing an account with Abbott.

Instructions : Please select the Abbott product division (select all that apply) you would like to open an account with and click Continue to complete the application online. To request a Credit Application for Abbott Nutrition, or to print and submit the application via email for other divisions and Canadian customers please follow the instructions at the bottom of the page.

Once your application has been processed, our Customer Service & Support team will contact you with your account information. Contact Us with any questions regarding the application process.

SELECT YOUR DIVISION*

> Core Diagnostics

Diabetes Care

Molecular Diagnostics

Nutrition

Point of Care

Information
Bill-To & Ship-To Information
Customer Information
Credit Information
Acknowledgement
Order Form (Optional)

Important Note: Using your browser's Back button within the Credit Application form will cause any data entered to be lost from the page you are on. Please use the Previous/Next navigation buttons at the bottom of each page.

Reason For Action

New Abbott Account

New Abbott Ship-To Account

Bill-To Number*

Bill-To Information

Full Legal Name*

ATTN

Years in Business

P.O. Box
(physical street address required for billing purposes)

Street*

City*

Country*

Zip Code/Postal Code*

State/Province*

Contact Name*

Title*

Phone*

Email*

GLN No.

Ship-To Information

Ship-To is same as Bill-To address

Name*

ATTN

Street*

City*

Country*

Zip Code/Postal Code*

State/Province *

Contact Name*

Title*

Phone*

Email*

GLN No.

To add additional Ship-To locations that you would like to use with the Bill-To information you provided above, please click the ADD SHIP-TO LOCATION button to add up 5 Ship-To locations in total. You may also upload this information using Document Upload in the CREDIT INFORMATION section.

Parent Company Information

Parent Company Name

Street

City

Country

Zip Code/Postal Code

State/Province

Contact Name

Phone

DUNS No.

Primary Bank

Name

Account Number

Address

Contact Name

Phone

Credit References

Name

Account Number

Address

Contact Name

Phone

+ Add Another Credit Reference

Credit Details

Anticipated Monthly Purchases

Credit Amount Requested

Document Upload

Please attach supporting documents such as Tax Exempt Certificate, Balance Sheet, Income Statement etc. (Note: If under Tax Status you have selected "Exempt" you must upload Tax Exemption Certificate(s)).

Choose a file

File Name

Supported file types: .doc, .docx, .xls, .xlsx, .pdf, .txt, .csv, .jpg, .png, .gif, .tiff.

Choose a file

File Name

Supported file types: .doc, .docx, .xls, .xlsx, .pdf, .txt, .csv, .jpg, .png, .gif, .tiff.

Choose a file

File Name

Supported file types: .doc, .docx, .xls, .xlsx, .pdf, .txt, .csv, .jpg, .png, .gif, .tiff.

Combined uploaded files should not exceed 5mb.

Customer Acknowledgement Required

Customer hereby authorizes the bank references listed herein to release all information requested. Customer agrees that all amounts that are payable on or before the net due date, as shown on each invoice, will be paid by such date and if not paid on or before such date are then delinquent.

If customer's account is placed for collection, customer agrees, in addition to the principal amount owed, to pay collection and/or attorney fees of 25% of the delinquent amount.

Customer further agrees that any controversy arising in any dealings between the parties shall be governed by and interpreted in accordance with the laws of the state of Illinois and, at Abbott's option, to submit to the jurisdiction of the courts (state or federal) located in the state of Illinois.

I hereby attest to the accuracy of the information entered upon this application. Further, I certify that the name, address, DEA Registration Number and schedules entered on or attached to this form are identical to the information listed on my current federal DEA registration certificate.

I hereby agree to immediately notify Abbott Laboratories of any change of ownership, name, address, DEA registration, DEA status, state pharmacy license number, or state tax status.

I Agree*

FreeStyle Libre Pro Customer Acknowledgement Required If Purchasing FreeStyle Libre Pro

Terms specific to Freestyle Libre Pro: for purchases of the Freestyle Libre Pro flash glucose monitoring system and components thereof ("Freestyle Libre Pro"), you agree that all such purchases (including those made through phone, fax, electronic data interchange (edi), email and online) are subject to the Freestyle Libre Pro flash glucose monitoring system terms and conditions located at e-Abbott.com, as amended from time to time.

By placing an order to purchase Freestyle Libre Pro, you are agreeing to be bound by those terms and conditions. You represent and warrant that you are licensed by applicable state law(s) to use or order the use of prescription medical devices in the course of your professional practice.

Only product(s) that you notify Abbott Diabetes Care were damaged during transit within 10 days of shipment may be returned to Abbott Diabetes Care. See e-Abbott.com for more information.

I Agree*

Name (Must be Authorized Representative of Company)*

Title*

Phone*

Email*

Or
(Complete Registration & Create New Order)

Ship-To Information

Select Ship-To*

Name*

Attn

Street*

City*

Country*

Zip Code/Postal Code*

State/Province*

Contact Name*

Title*

Phone*

Email*

Purchase Order *

Note: Purchase Order required only if you select a product in quick order below

QUICK ORDER BY Product Number

Product Number - Description	Quantity	Unit	Unit Price	Total Price	Minimum Order Qty

New Credit Application
*Required Field

SELECT YOUR DIVISION*

Reason For Action

Bill-To Information

Ship-To Information

Parent Company Information

Accounts Payable Contact

Purchasing Contact

Customer Type*

Company/Industry/Class of Trade Type*

State & Federal Tax Status

Primary Bank

Credit References

Credit Details

Document Upload

Customer Acknowledgement Required

FreeStyle Libre Pro Customer Acknowledgement Required If Purchasing FreeStyle Libre Pro

Ship-To Information

QUICK ORDER BY Product Number

Confirmation

Captcha

New Credit Application *Required Field

SELECT YOUR DIVISION*

Reason For Action

Bill-To Information

Ship-To Information

Parent Company Information

Accounts Payable Contact

Purchasing Contact

Customer Type*

Company/Industry/Class of Trade Type*

State & Federal Tax Status

Primary Bank

Credit References

Credit Details

Document Upload

Customer Acknowledgement Required

FreeStyle Libre Pro Customer Acknowledgement Required If Purchasing FreeStyle Libre Pro

Ship-To Information

QUICK ORDER BY Product Number

New Credit Application
*Required Field