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*
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*
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 (You really should be reading this)*
View our Privacy Policy and Terms of Use
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COVID-19 Vaccinations are now available at VLS Pharmacy in Brooklyn, NY.
If appointments are unavailable, please check back frequently as New York State is systematically allocating vaccines. As we receive more vaccines, more spots will open.
Please note: we CANNOT book your appointment over the phone due to the screening requirements.

Please text us with your prescription refill requests: VLS Pharmacy: 844-857-5588 | New Drug Loft: 212-879-0910.

New Prescriber Account Form

Shipping Information