Clinic Self Registration

Name *

Address *

State *

City *

Zipcode *

Phone *

Drug Category *

Marketer

Billing email *

Billing Preference *

Payment Method Authorization *

Because this clinic will be billed directly, the provider must complete the ACH Payment Method Authorization via DocuSign before registering.
Open Payment Method Authorization form (DocuSign)

I have completed the Payment Method Authorization via DocuSign

Shipping Preference *

First Name *

Middle Name

Last Name *

NPI *

DEA #

Supervising physician

First Name *

Last Name *

Email *

Phone *

Role *

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