Enroll Now

Before enrolling with Encore Surgical Supplies, ensure you have the following information available:

New Client Enrollment

Which program(s) are you enrolling with?

HealPACK (Collagen Dressings) Skin Subs (CAMPs)

What is your email?

Practice Information

Legal Practice Name

DBA

Practice EIN / Tax ID Number

Facility Type 2 NPI#

Street Address

Street Address 2

City

State

Zip Code

Practice Phone #

Practice Fax #

Practice Domain

Practice Logo for Documentation

Agreement

Please note: A signed agreement is required before your enrollment can be approved.

If you haven’t received one, please reach out to your sales representative.
You may still complete this form—your enrollment will remain pending until the agreement is fully executed.

Contract Signer First Name

Contract Signer Last Name

Contract Signer Email

Portal Setup

A Portal will be created for your account. The contacts listed below are required to ensure proper staff access and automated notifications.
The contacts below will receive invitations to the Portal and be contacted by our onboarding team for training.

Who is our main point of contact for onboarding and Portal setup?

First Name

Last Name

Who will be submitting patient information in the Portal?

This contact is who will be submitting patient information in the Portal for insurance verification and receive alerts if additional patient documentation is required.

Full Name