Welcome to the Furoscix Direct enrollment page. To submit an enrollment request, please fill in as much detail as possible about your practice and doctors. All fields marked with an asterisk (*) below are required. All information provided will be stored in your browser session and will be automatically deleted when your session expires ( after there has been no action in at least 15 minutes). Furoscix Direct uses the information you submit on this form to process your enrollment request. By clicking on the "Submit Enrollment" button below, you agree that the information you provide will be governed by our site Privacy Policy.