Join Us

If you are interested in becoming a Blackwing Prescrition Foods Affiliate, simply fill out and submit the Prescrition Foods Affiliate application below. Your submitted information will be reviewed and you will be contacted regarding acceptance of your application. Please rest assured that Blackwing will not sell or otherwise disclose any of your submitted infomation for any purpose. If you have any questions, please email us at pfinfo@blackwing.com or call us at (800) 326-7874.

Affiliate Contact Information
		* denotes required field
* Company
* First Name
* Last Name
* Address 1
Address 2
* City
* State
* Zip
* Phone
Fax
* Email
Affiliate Healthcare Information
* Type of Practioner
License Number
Tax ID
* What geographic area does your practice cover?
* Do you prescribe diet for your patients/clients?
* Do you lecture?
* What is the size of your practice?
Are you planning on expanding your patient/client base using Blackwing's Prescription Food Program?
* How did you hear about us?
How will the Prescription Foods Affiliate Program benefit your and your clients?