Program Application Form

The Health Care Practitioner Account Application Form is required to establish your wholesale LactiGo account with access to exclusive practitioner pricing. Submitting this form initiates your onboarding process so we can set everything up for you.

Please note: Health Care Practitioners will also need to create an affiliate account if they have not already done so. To complete this step, please obtain the affiliate sign-up link from the person who referred you to LactiGo. This will ensure your affiliate account is properly linked to your wholesale account. That person will also be your key contact with your business practice.

Our team is currently handling a high volume of requests, so response times may take a little longer than usual. Thank you for your patience!

Primary Contact Information

Account *

Business Address *

City

State

Postal Code

Full Name *

Title / Role

Phone *

Email *

Website

Practice Details

Type of Health Care Professional

Provide Your License Number

Who Referred You or Person Who Contacted You *

Additional Business Details

Acknowledge by clicking the circle *

I acknowledge that the minimum order size to qualify for wholesale pricing is $700 USD, and subject to changes by Lactigo, Inc. The wholesale program provides 30% off on wholesale bulk purchases. Samples are available upon request. Just let us know.

Signature *

Clear

Use Your Mouse to write Signature

Privacy Policy | Terms of Service

User fully agrees to receive both text messages and phone calls. User understands that calls may be automated, pre-recorded, or use an Ai voice. User fully understands and agrees to receive marketing communications from Hazel Group Marketing. And, user can opt out at anytime for any and all future messages