New Prescriber Account Form — New Drug Loft and VLS Pharmacy

If you are a prescriber, please complete our new account form below. We will be in touch soon to complete the sign-up process!

Licensed Prescriber Name*

Credentials*

Credentials: Please Specify*

Please enter your credentials

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

State License #

NPI*

DEA Number*

Address*

Address City State ZIP Code

Phone

Fax

Office Contact

Alternate Phone

Email Address*

Email for Invoices*

How Did You Hear About Us?*

How did you hear about us? Please describe:*

I would like to receive updates on:

Consent*

I agree to the Privacy Policy and Terms of Use (You really should be reading this)*

CAPTCHA

Help us prevent SPAM by confirming the CAPTCHA.