Registration

please complete the form below to receive your VIP - Veterans Imaging Products E-Way User ID and Password. So we may best serve you, please complete as much information as you can on the form and allow 24 hours for account set up or maintenance to take effect. Please do NOT provide Credit Card Information in this request!

Questions?
Toll free #: 866-602-8259 fax#: 866-602-8260
Local #: 630-671-9290 fax#: 630-351-7218
Email: veterans@veteransimaging.com

* Symbol denotes required field.
Veterans Affairs Customers Click Here!
 

1.

 Please enter the following information about yourself. Please be sure to fill out all fields.

     

*Name
*Department/Agency
*Service/Agency of Assignment
 Other Department/Agency/Service
*Building/Room #/Mail Stop #
*Shipping Address
 Shipping Address 2
  *City
  *State
*Zip
 
*Phone (XXX) XXX-XXXX Ext
 FAX (XXX) XXX-XXXX
*E-mail
How did you hear about our site?
 
Referral Information
Account Manager

2.

 If you place orders for more than one shipping address, please include additional street address, city, state, and zip in the Additional Comments field. You may enter any other additional comments as well.

 

 Additional Comments

3.

 Click Submit below to send us your Registration Information.