QU - Submission Page - FIRST ALTERNATIVES

QU - Partnership Portal Page

This page is for facilitating our agreement between QU and FA in order to send the necessary information back and forth and we can edit it as we need to facilitate this process.

Program Initiation Form

* Indicates required field

Authorizing Admin *

First

Last

Point Of Contact Phone Number *

Email *

Program ID # ( Ex: QU1 ) *

Program Description -> (1)What items to be offered, (2)What Collateral to be slipped into the package, (3) What branded information should we assign to the patient as far as training and links *

Collateral to be inserted into package ( pdf preferred pleased ) *

Max file size: 20MB

Payment on File

Name on Account ( First Name Last Name ) *

Credit/Debit Card Number *

Expiration Date (MM/YY) *

Billing Zipcode *

Or

First Name Last Name on Account *

Bank Name *

Account Number *

Routing Number *

Billing ZIp For Account *

admin password for order use ( ex: Sunny123 ) for authorizing orders *

Any Extra Comments or Request *

Initiate your Program Now

Program Ticket Submission

* Indicates required field

Shipping Name *

First

Last

Email *

Phone Number For Shipper *

Drop Ship Address *

Line 1

Line 2

City

State

Zip Code

Country

Program ID *

Admin Authorization Password *

Authorize Order and Ticket Submission

QU - Partnership Portal Page

Program Initiation Form

Payment on File

Or

Program Ticket Submission

Or For Bulk Submissions

First Alternative Therapies

www.FirstAlternativeTherapies.com

[email protected]

Office: 954-789-2097

Fax: 772-872-6620

First Alternatives Representative Portal

www.fareps.com

[email protected]

First Alternative Care

www.firstalternativecare.com

[email protected]

FA Better Body Center

www.fabetterbody.com

[email protected]

QU - Partnership Portal Page

Program Initiation Form

Payment on File

Or

Program Ticket Submission

Or For Bulk Submissions

First Alternative Therapieswww.FirstAlternativeTherapies.com[email protected]Office: 954-789-2097​Fax: 772-872-6620

First Alternatives Representative Portalwww.fareps.com[email protected]

First Alternative Care​www.firstalternativecare.com[email protected]

FA Better Body Centerwww.fabetterbody.com[email protected]

First Alternative Therapies

www.FirstAlternativeTherapies.com

[email protected]

Office: 954-789-2097

Fax: 772-872-6620

First Alternatives Representative Portal

www.fareps.com

[email protected]

First Alternative Care

www.firstalternativecare.com

[email protected]

FA Better Body Center

www.fabetterbody.com

[email protected]