International Practitioner Registration Packet

International Practitioner Registration Packet
Dear International Healthcare Practitioner,

College Pharmacy is one of the few compounding pharmacies able to work directly with healthcare practitioners and patients throughout the world. From Egypt to Ireland, and Brazil to New Zealand, we are honored to offer services that know no global boundaries.

Working directly with International healthcare practitioners for over a decade has allowed us to gain valuable experience in the compounding and delivery of sensitive formulations.

Our pharmacists, customer service representatives, and shipping specialists are experienced in the nuances of international shipping practices and help customers navigate changing international practices and procedures.

Before we can begin filling prescriptions there are a few things we need:

1. Copy of your medical license: translated into English if it is not already.

2. Patient specific prescriptions require a date of birth, patient allergies, and specific directions for use. All prescriptions must be signed. Electronic signatures are accepted.

3. “Office Use” orders require the signature of the practitioner. Electronic signatures are accepted.

4. Billing and Payment Information: see attached form for details.

5. Copy of our international shipping disclaimer and acknowledgement of our return policy signed and returned to College Pharmacy: see attached for details.

6. Please visit the following website for any special rules and requirements of the destination country: http://www.fedex.com/us/international/irc/profiles/?link=2

Please let us know if you have any questions about setting up your account with College Pharmacy. We will be happy to assist you.

Sincerely,

The College Pharmacy Staff
International Practitioner Ordering & Payment Agreement

Billing Information: Must Be Completed Prior To Filling A Prescription Order. Please Print Information Clearly.
HEALTHCARE PRACTITIONER INFORMATION:
Registration Date:*

MonthDayYear
Date
Practitioner Full Name*

First NameMiddle NameLast Name
Professional Designation / Title: *
Medical License #:*
Street Address:*
City:*
State:*
Country:*
Zip/Postal Code:*
Email:*
Phone*

Area CodePhone Number
Fax:*

Area CodePhone Number
CREDIT CARD & PAYMENT POLICY:

Please select a billing option
*Important: Unless you choose “Wire Transfer” as your payment option, College Pharmacy will automatically bill your credit card.
Please choose your billing option*

Credit Card: a photocopy (front and back) of the credit card, and a photocopy of the cardholder’s ID arerequired for processing. Any credit card declines could delay your orderWire Transfer: $40 wire transfer fee will be assessed and a 10% - 20% international security deposit isrequired to be on file.
BILLING INFORMATION:

College Pharmacy requires an active credit card on file to process orders. Your order could be delayed if we have problems processing payment or contacting you for payment clarifications.
Name On Credit Card:*
Credit Card Number:*
Exp. Date:*
Mailing Address of Card Holder:

Same as mailing address above
Street Address:
City:
State:
Country:
Zip/Postal Code:
Print Full name:*
Signature*

Clear
Date:*
International Shipping Disclaimer: Due to international shipping regulations, I understand that any package sent by College Pharmacy to anywhere outside the United States might not pass through or be delayed by customs in the country to which it is being shipped. Knowing the risk, I wish to place an order with College Pharmacy, and agree to pay for my order, regardless of whether or not I receive the package. If I do not receive my order, I have the right to request proof of non-delivery, including any paperwork that accompanied the return of the order. If I would like another order re-shipped, I may request it at my own expense and risk. In addition, certain medications do not ship well overseas. College Pharmacy reserves the right to decline to send an order of a certain medication if we foresee problems with its transportation to the desired destination.

Ordering & Payment Policy: When you fill a prescription with College Pharmacy, you are both ordering and purchasing a preparation and service that requires payment in full. If you are ordering a compounded formula, your prescription is being compounded for you by a team of specially trained compounding technicians and pharmacists with specialized equipment, and is being processed by a specially trained staff of customer service operators. Services may also include commercial products that we have specially stocked to fill your order. Unless you choose “Wire Transfer” as your payment option, College Pharmacy requires an active credit card on file to process orders. Your order could be delayed if we have problems processing payment or contacting you for payment clarifications. You are responsible for notifying College Pharmacy of a change in credit card information AND completing a new “Ordering & Payment Agreement” when changing your credit card on file.

Chargeback Policy: If you have a question about a charge from College Pharmacy, we encourage you to contact us directly to research the issue. Chargebacks are costly and time-consuming for us to resolve. College Pharmacy reserves the right to refuse credit card payment from credit card decline and chargeback accounts on all future orders. Credit card decline and chargeback accounts will be required to pay in full via wire transfer (includes additional fees).

Return Policy: We regret that we cannot accept returns on any custom compounds, commercial prescription products, or over-thecounter nutritional supplements. State regulations prohibit the return and resale of such items. We encourage chemically sensitive patients to discuss any problems with their healthcare practitioners and thoroughly inquire about ingredients before filling a prescription with College Pharmacy. You also may request smaller quantities of new prescriptions until you are sure the medication can be tolerated. If there are any concerns, please call the Customer Service Department at (719) 262-0022 or (800) 888-9358 within 24 hours of receiving your order.
I understand that any package sent by College Pharmacy to anywhere outside the United States might not pass through or be delayed by customs in the country to which it is being shipped. (initial): blanks*
I understand the International Shipping Disclaimer and agree to pay for my order, regardless of whether or not I receive the package. (initial): blanks*
I have read, understand, and agree to College Pharmacy’s Ordering & Payment Policy. I understand that I am responsible for the payment of my order through College Pharmacy. (initial): blanks*
I authorize College Pharmacy to process payments on the credit card provided on page #1. (initial): blanks*
I understand my order could be delayed if College Pharmacy is not able to process payment. (initial): blanks*
I have read and understand College Pharmacy’s shipping services and fees. I understand that additional charges, based on weight, will be added to the standard rate that I select for my order. (initial): blanks*
I have read, understand, and agree to College Pharmacy’s Chargeback Policy. I understand that College Pharmacy reserves the right to refuse future credit card payment options on chargeback accounts. (initial): blanks*
I understand that College Pharmacy does not accept returns of custom compounded prescriptions, commercial prescription products, or over-the-counter nutritional supplements. (initial): blanks*
Print Full name:*
Signature*

Clear
Date:*
International Shipping Label

Must Be Completed Prior To Filling A Prescription Order. Failure To Respond Within 24 Hours Will Delay Your Order. Please Print Information Clearly
Please PRINT the complete shipping address EXACTLY as it should appear on the package.
Company Name:*
Recipients:*

First NameLast Name
Street Address:*
City:*
State:*
Country:*
Zip/Postal Code:*
Email:*
Phone Number*

Area CodePhone Number
Fax Number*

Area CodePhone Number
Special Instructions:*
Credit Card Authorization Form
Name on Card:*

First NameLast Name
Billing Address:*
Credit Card Type:*
Credit Card Number:*
Exp. Date:*
Phone Number*

Area CodePhone Number
Email:*
Items purchased:
blanks* OTC Product(s)
blanks* Compounded Prescription(s)
blanks* Medical Device
Amount to charge:
$blanks*
I authorize College Pharmacy to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder - Please Sign and Date
Print Full name:*
Signature*

Clear
Date:*
3505 Austin Bluffs Pkwy., Ste. 101
Colorado Springs, Colorado 80918

www.collegepharmacy.com

Tel: 800-888-9358 / 719-262-0022
Fax: 800-556-5893 / 719-262-0035
e-Fax: 866-480-7483

STORE HOURS

Mon - Fri: 8:30am - 6:00pm
Sat & Sun : On Call

newpatient@collegepharmacy.com
Should be Empty:

International Practitioner Registration Packet

International Practitioner Ordering & Payment Agreement

HEALTHCARE PRACTITIONER INFORMATION:

CREDIT CARD & PAYMENT POLICY:

BILLING INFORMATION:

International Shipping Label

Credit Card Authorization Form