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Increased sales, reduced hassles
and Uncommonly Good Customer Service!

Doctors Supplement Store Online Signup

FREE, no-risk setup (U.S.-based healthcare professionals only)

Please email of call if you need assistance.

About Your Practice
Full Name: *

First Name Last Name
Degree/Credentials: *
E-mail: *
Your Practice Name and Address will be displayed on your online store and on patient order receipts.
Practice Name:
Practice Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Country
Practice Phone Number *
Practice Phone Number
Practice Website:
Why did you choose Doctors Supplement Store?
How did you hear about us?
Referral or Promo Code (if applicable)
Please provide an additional contact, such as an Office Manager, if applicable.
Contact Name

First Name Last Name
Position
Email:
View our Terms of Service. (Recommended)
Phone
Please Check: *

I agree to the Terms of Service on the previous page. The information provided in this application is complete and accurate to the best of my knowledge.

Customizing Your Store

NOTE: Options can be changed at any time by contacting us.
Orientation

The best way to learn about your store and your Control Panel is to participate in a brief, live online orientation. Indicate a good time or leave blank if you'd prefer to schedule this later.
Orientation Date

Month Day Year Hour Minutes AM/PM Option
My Time Zone:
I prefer not to have an orientation (not recommended)
Website Address for Your New Store

Enter the word or phrase to use after www.DSSOrders.com for your store's web address:
Word or Phrase to Use: *
Example: www.DSSOrders.com/DrSmith
Notification Email Address

Enter the email address for notifying you when patients register and order.
Notification Email Address: *
Site-Wide Discount (optional)

You may discount prices across-the-board on your site. IMPORTANT: This is a percentage of *your* profit, not a percent off the retail price!! EXAMPLE: If a product retails for $40 and wholesales for $20, then you earn $10 (half the gross profit). A 20% site-wide discount would save the patient $2 (20% of your $10 earnings.)
Enter the percent of your earnings to forego and pass along to patients:
IMPORTANT: THIS IS NOT A PERCENT OFF THE RETAIL PRICE. (See example above.)
Multi-Provider Tracking

If more than one health care provider at your practice will be selling supplements through our service, and you'd like to track sales by each provider, list the names of the providers as they should appear to patients.
List names if more than 1:
Customized Banner

A banner will appear everywhere your patients interact with our service, including emails we send. Choose how you would like it to appear.
Please make a selection: *

Use the logo or graphics found on my practice website. Use a logo I will upload below. Create a "generic" banner with my name and practice name. Use the Doctors Supplement Store logo.
Comments/Requests
Upload Your Logo (if second option above is selected)
Coupons (optional)

We can create coupon codes for patient discounts. You may specify the dates available, minimum purchase amount, and a percent or dollar discount. We can create coupons for you at any time. Discounts come out of your earnings.
Select any coupons you'd like us to create:

Save 10% on your first order ("welcome" coupon) Save 10% on orders over $250 Employees save 20% (for you or your staff)
Describe any other coupons you'd like us to set up at this time. (See description above for options.)
Other Comments or Requests:

ALMOST DONE!

NOTE: You don't have to provide the documents below at this time, but we won't send earnings checks until we receive them.

To skip this for now, continue to the Submit Signup Form button on the last page.

You must click the Submit button to complete your signup!
LICENSE OR CERTIFICATION

We request a copy of your license or certification to be in compliance with certain manufacturers who exclusively sell to certified health care providers.
There are 3 ways to provide your license or certification:

1. Take a picture of it with your smart phone and email it to support@dssorders.com.

2. Scan it, save it to your computer and upload it below.

3. Fax it to 877-903-9290.
Upload Your License or Certification

W-9

This simple form instructs us how to report your earnings to the IRS, if required.
How would you like to submit your W-9? *

Fill out an electronic W-9 form (recommended) Fill out a paper W-9 form to upload, fax, or scan and email to us

W9: Request for Personal Taxpayer ID Number
IMPORTANT

We will need Your Name and SSN -OR- Your Business Name and EIN, but not both.

We need a single tax ID to report earnings against when required by the IRS.
To whom should we make out your earnings checks? *

Make earnings checks out to my business Make earnings checks out to me personally

W9: Request for Personal Taxpayer ID Number
Your Name (exactly as shown on your personal income tax return)
Social Security Number XXX-XX-XXXX
If you are completing the W-9 at this time, by submitting this form you attest the following:

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.

W9: Request for Business Tax ID Number
Your Business Name (exactly as shown on your income tax return)
Employer Identification Number (EIN) XX-XXXXXXX
Enter your tax classification
Check appropriate box for federal tax classification

Individual/sole proprietor or single member LLC C Corporation S Corporation Limited Liability company. *Enter Classification Below
* If Limited Liability company checked above Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
If you are completing the W-9 at this time, by submitting this form you attest the following:

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.

W9: Request for Taxpayer ID Number
IMPORTANT

We will need Your Name and SSN -OR- Your Business Name and EIN, but not both.

We need a single tax ID number to report earnings against when required by the IRS.
1. Download the W9 form here AND THEN:

2. Scan it, save it to your computer and upload it below.
3. Scan it and email it to support@dssorders.com
4. Fax it to 877-903-9290.
Upload completed W-9

Payment Address
Where should we send your earnings checks?
Send to my practice address
Street Address (if not sending to practice address)
City, State, and ZIP code

Last Step -- Just Click Submit!

When your form has been submitted, you will see a Thank You message.
Should be Empty:

About Your Practice

Brand Selection

Customizing Your Store

Orientation

Website Address for Your New Store

Notification Email Address

Site-Wide Discount (optional)

Multi-Provider Tracking

Customized Banner

Coupons (optional)

LICENSE OR CERTIFICATION

W-9

W9: Request for Personal Taxpayer ID Number

W9: Request for Personal Taxpayer ID Number

W9: Request for Business Tax ID Number

W9: Request for Taxpayer ID Number

Payment Address