Language
English (US)
NEW MEDICAL PRACTICE
ACCOUNT INFORMATION
PRACTICE INFORMATION
Business Name
*
Business Phone Number
*
Please enter a valid phone number.
Business Fax Number
Please enter a valid phone number.
Business/Shipping Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Website
Primary Therapeutic Area of Interest
*
Please Select
Allergy
Animal Health
Anti-Infective / Wound Care
Functional Medicine
GI / Colorectal
Hormone Replacement
Hospice / Long Term Care / Hospital
Infectious Disease
IV Nutrition
OB/Gyn (non-hormone)
Oncology
Opthalmic
Otic
Pain Management
Respiratory (non-infectious disease)
Skin Care (Dermatology, Cosmeceuticals, Hair Loss)
Specialty Commercial Medications
Urology (non-hormone)
Weight Loss
Other Primary Therapeutic Area(s) of Interest
Men's Health
Urology
Women's Health
Hormone Replacement Therapy
IV/IM Nutrition
Pain Management
Weight Management
Ophthalmology / Otolaryngology
Skin: Dermatology / Cosmeceutical
Gastroenterology / Colorectal
Functional Medicine
Business Partnership
Allergy Immunotherapy
Other
Primary Contact
*
First Name
Last Name
Preferred Method of Contact
*
Please Select
Cell Phone
Office Phone
Email
Primary Contact Email
*
example@example.com
Primary Contact Phone
Please enter a valid phone number.
Shipping Contact Name
First Name
Last Name
Shipping Contact Email
*
example@example.com
Days and Hours of Operation
*
Primary Payor
*
Office
Patient
Both
Billing Information
In an effort to protect your security, we do not collect credit card information online. A representative from Eastern States Compounding Pharmacy will contact the designated billing contact to collect credit card information within 24-48 business hours after receipt. If you need to make changes to your billing contact or credit card on file, please contact the pharmacy direct at (800) 964-0094.
Name of Person Responsible for Billing:
*
Phone Number to Contact for Billing:
*
Please enter a valid phone number.
Email Address of Person Responsible for Billing:
*
How Did You Hear About Us?
*
Conference (Please Write Which Conference in the "Other" Field
Referral (Please Write Who Referred You in the "Other" Field)
Newsletter / Email
Salesperson (Please Write the Salesperson's Name in the "Other" Field)
Search Engine / Social Media / Website / Blog
Other
Signature
*
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Today's Date
*
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Month
-
Day
Year
Date
Printed Name
*
First Name
Last Name
Job Title
*
Please Verify That You Are Human
*
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