BlackBoxRX • BlackBoxRX • Single User Registration

Please fill out the form below to register for a single user license for BlackBoxRX

You will be charged $$89.00 for a one year membership.

Account Information

First Name Last Name Email (Used for Login)

Enter Password Retype Password

Facility Info (Optional)

Facility Name Office Phone Occupation Occupation (other) Practice/Site Type Facility Type (other)

Address Line 1 Address Line 2 City State Zip Code

Payment Information

Credit Card Number Expiry Date CVV2/CID ?

Billing Name Billing Phone Billing Address Line 1 Billing Address Line 2

Billing City Billing State Billing Zip code

By clicking Submit, you are agreeing to the Terms of Use for BlackBoxRX.