Practice Registration Form
Practice Name
*
Rep Name
*
Rep Phone Number
*
Rep Email
*
example@example.com
Distributor Company Name
*
Distributor Name
*
Distributor Email
example@example.com
Specialty
*
i.e. Family Medicine
Clinic Contact Name
*
Clinic Address
*
Street
Street 2
City
State
Zip Code
Clinic Phone
*
Clinic Fax
Clinic E-mail
Payor Mix
Commercial %
1
Federal %
2
Self-Pay %
Anticipated Monthly Volume
List All Providers
1. Provider's First Name
*
1. Provider's Last Name
*
1. Provider's Degree (ex M.D., D.O....)
*
1. Provider's NPI Number
*
1. Provider's DEA Number
*
1. Provider's Cell
1. Provider's Email
2. Provider's First Name
2. Provider Last Name
2. Provider's Degree (ex M.D., D.O....)
2. Provider's NPI Number
2. Provider's DEA Number
2. Provider's Cell
2. Provider's Email
3. Provider's First Name
3. Provider's Last Name
3. Provider's Degree (ex M.D., D.O....)
3. Provider's NPI Number
3. Provider's DEA#
3. Provider's Cell
3. Provider's Email
4. Provider's First Name
4. Provider's Last Name
4. Provider's Degree (ex M.D., D.O....)
4. Provider's NPI Number
4. Provider's DEA Number
4. Provider's Cell
4. Provider's Email
5. Provider's First Name
5.Provider's Last Name
5. Provider's Degree (ex M.D., D.O....)
5. Provider's NPI Number
5. Provider's DEA Number
5. Provider's Provider's Cell
5. Provider's Email
Check all script pads required
Primary Pad- Internal Medicine/ Primary care/ Family Practice/ Urgent Care
Pain Pad
Men's and Women's Health Pad
Gastro Intestinal Pad
Podiatry Pad
Urology Pad
Surgical Pad
Pain and Workers Comp Pad
Master with No Testosterone Pad
Master with No Ed (Slldenafil) Pad
Master with Wellness Pad
Where should the Script Pad be sent?
Directly to practice
Send to Distributor/ Rep
If sending to Distributor/ Rep, what is the mailing address?
Additional Information
Closing Date
-
Month
-
Day
Year
Date
Stage
Deal Owner
Submit
Should be Empty: