New Account Request
Where health and partnership meet.
CONTACT DETAILS:
First Name
Last Name
Applicant Title
--None--
Owner
Owner/Prescriber
General Manager
Pharmacy Liasion
Prescription Order Management
Accounts Payable
Other
Email
Phone number
PRACTICE DETAILS:
Practice Name
Practice Website
How many locations do you have for your practice?
How many prescribers are in your practice?
How do you see your patients?
Average patients per day?
How did you hear about us?
Is your Practice part of a network or franchise?
--None--
Yes
No
Practice Address:
Country
--None--
United States
Street
City
State/Province
--None--
Arizona
California
Delaware
Florida
Hawaii
New York
Zip/Postal Code
ADDITIONAL INFORMATION:
Which therapeutic areas are you interested in?
Custom Compound
Dermatology
Fertility
Hormone Replacement
Injectable Supplies
IV Therapy & Supplements
Nausea
Ophthalmology
Peptide Therapy
Sexual Wellness
Shipping
Thyroid
Vitality
Vitamins/Supplements
Weight Management
What is your current method of prescription transmission?
--None--
LifeFile ERX
EMR/EHR Surescripts
EMR/EHR API
EMR/EHR Fax
Fax
Other
Please list medication(s) of greatest interest
Please provide additional information about your practice to help us better serve you
Submit New Account Request
