New Provider Account Form

Practitioner/Practice Information:

Clinic Address(Required)

Billing Information

Billing Address(Required)

*. For your convenience, credit cards are securely stored on file for all office orders and bill clinic prescriptions. All invoices are sent via email upon order completion and due upon receipt. Credit cards will automatically be charged prior to delivery and/or pick-up.

I hereby authorize the following individual(s) to execute for on behalf of the named entity/organization and physician, any actions necessary for the purpose of procuring prescription drugs.

These actions include placing new orders either by phone, e-scripts, fax, picking up office orders, and allowing the authorized agent to engage in dialogue with the pharmacy about patient specific prescription products. If there is ever a change in the authorized agents, the physician must submit a new form.

This form is required even when the authorized agent is the executive authority themself.

A copy of the physician’s license is a requirement for the above agreement. Controlled substance ordering requires a copy of a DEA license.

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In order to process your account application, we require a copy of your valid practitioner's license and DEA license (if dispensing controls).
Drop files here or
Accepted file types: jpg, pdf, png, Max. file size: 5 MB, Max. files: 5.