Prescriber Registration

 

We invite you to submit the information requested below so we can deliver superior service to your office .

Only the items marked with a ‘*’ are 100% necessary – all other information is optional at the moment, but will help us to serve you more quickly.

After we receive your submission, we will be in touch to assist you.

Your privacy and the security of the information submitted is our foremost priority, and your confidential information will never be shared or distributed without your authorization.

Suffix

First Name (required)

Last Name (required)

Specialty

Office Address

Telephone (required)

Fax

Email (required)

Approximate % of Workers' Comp

Interested in custom compound medications?

Interested in a dispensing program for transdermal compound medications?

Best day to reach you?

Best time to reach you