New Prescriber Account Form

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
State License #
NPI
DEA Number*
Address
Address City State ZIP Code
Phone
Fax
Office Contact
Alternate Phone
Email Address*
Email for Invoices*
Shipping Information
Licensed Prescriber Name
Contact person for shipments to be sent to (optional)
Address
Check this if the shipping address is same as above
Address City State ZIP Code
Phone
Email Address for Tracking No.*
Signature required for shipping?
- Yes
- No
Notes
How Did You Hear About Us?*
Consent*
I agree to the Privacy Policy and Terms of Use*
View our Privacy Policy and Terms of Use
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Due to high demand and call volume, please TEXT us with your refill requests: VLS Pharmacy: 844-857-5588 | New Drug Loft: 212-879-0910. We will return your text, please be patient with us. More important COVID-19 information HERE.

New Prescriber Account Form

Shipping Information