New Prescriber Account Form

If you are a prescriber who needs an order filled or a patient with a prescription refill, please choose one of the following options below:

If you are a licensed prescriber in the United States, please complete the form below and we will respond within two business days.

Please be aware that if you are a patient, you will not receive a response if you submit the form below. Unfortunately, we cannot respond to non-prescriber inquiries related to this form. Please select one of the options above. Thank you.

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Licensed Prescriber Name*

Credentials*

Select CredentialsMDDOPANPRNLPNDDSDMDODDPMDVMRPhPharmDPsyDDCMedical AssistantNon-Medical StaffOther

Are you currently or are you planning to provide IV Therapy?*

Select belowYes, brick & mortar locationNo

Please note: We are unable to prescribe for individuals administering IV therapy through mobile services.

Credentials: Please Specify*

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NPI*

DEA Number*

State License #

Address*

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Phone

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Office Contact

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Email Address*

Email for Invoices*

How Did You Hear About Us?*

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How did you hear about us? Please describe:*

I would like to receive updates on:

General News

Dermatology/Aesthetics

Integrative/Functional Medicine

Ophthalmic Compounding

Upload a copy of your Medical Director’s license:*

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Max. file size: 256 MB.

To Be Filled and Signed by the Medical Director

Printed Name of Medical Director*

Name of Practice*

I am aware that office administered medications:*

Are patient specific

Are to be administered only to the patient for whom the medication(s) are prescribed

Must be kept locked when the medical director is not on site to prevent unauthorized access

Are only administered by the Medical Director or by qualified personnel

Are governed by state and federal regulations, and I understand the regulations of the specific medications being prescribed and administered

Signature of Medical Director*

Consent*

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