Formulario de solicitud de acceso al portal del cliente Place An Order Portal Enrollment Portal Sign In Request/Forgot Password Distributor Tool Kit Customer Portal Request Step 1Are you currently purchasing direct from Halyard?NoYes If your organization is not a direct customer, then Customer Portal access is not available. If your organization is interested in purchasing Surgical and Infection Prevention products, please contact your distributor to find out what options are available. Step 2Please complete the following information to create your Customer Portal User ID:Customer Number(Obligatorio)Company Name:(Obligatorio)Company Address(Obligatorio) Dirección Dirección 2 Ciudad Estado / Provincia / Región ZIP / Código Postal United StatesCanadaMexicoPuerto Rico País Company Phone Number(Obligatorio)Company Fax NumberName(Obligatorio) Nombre Apellidos Email Introduce un email Confirmar email Department(Obligatorio)Accounting/FinanceAdministrationAnesthesiologyHospitalMarketingPharmacy/ChemistProcurementPurchasing/Materials ManagementSalesSurgical ServiceWarehousing and DistributionOtherJob role(Obligatorio)AssistantAuditorBuyerCoordinatorManager/SupervisorNurseOperationsPhysician/DoctorPhysician Assistant (P.A.)Sales RepresentativeSurgeonWorkerOtherHalyard RepIf you have other locations for your company where you will require Customer Portal access, please list them below. Each location must have a unique customer account number. If you need additional entries, please include them in the Comments box. Customer NumberCustomer Address Dirección Dirección 2 Ciudad Estado / Provincia / Región ZIP / Código Postal United StatesCanadaMexicoPuerto Rico País Customer NumberCustomer Address Dirección Dirección 2 Ciudad Estado / Provincia / Región ZIP / Código Postal United StatesCanadaMexicoPuerto Rico País Customer NumberCustomer Address Dirección Dirección 2 Ciudad Estado / Provincia / Región ZIP / Código Postal United StatesCanadaMexicoPuerto Rico País Customer NumberCustomer Address Dirección Dirección 2 Ciudad Estado / Provincia / Región ZIP / Código Postal United StatesCanadaMexicoPuerto Rico País Comments