New customer registration form

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Please complete the form on this page to begin the registration process. Fields marked with an asterisk (*) are required. Upon completion of this form, a representative will contact you to complete your application.

Prior to activating your account, we require you to provide the following:

  • A copy of your active State Board License
  • A copy of your active DEA License if applicable
  • A completed credit application:
    Download Credit Application

You may submit the credit application using any of these methods:

  • Email:
  • Fax: 800-687-8902
  • Mail: Attn: New Account Registration
    Letco Medical
    17199 Laurel Park Drive, Suite 315
    Livonia, MI 48150