New Account Setup

Number of Providers:

Multiple Locations?

YesNo

If Yes, How Many Locations?

Check all that apply:

Point Of Care DispensingRapid Diagnostic Testing503B Injections & CreamsMedical Supplies

Other Programs

Practice Name

Address

City

State

Zip Code

Practitioner Name

State License #

DEA License #

Full Name

Billing Phone

Billing Email

Billing Address

Billing City

Billing State

Billing Zip Code

Payment Method

Credit CardInvoice

Name of Person Who Will Be Receiving Monthly Statements

Statement Recipient's Phone

Attach Your Documents

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