Puramint Price or Medication Inquiry or New Initial Setup
Please complete the fields below to expedite your inquiry. After verifying, we will call or email you with the information you are requesting within 24-48 business hours. If you have an urgent need, please escribe first (or fax or call it in) and come back to this form.
What brings you to Puramint?
Practice Name
*
Practice Contact Name
*
Practice Contact Email
*
example@example.com
Practice Phone Number
*
Please enter a valid phone number.
Practice Fax Number
Please enter a valid phone number.
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prescriber Information
Number of Prescribers to Setup
*
One
Two
Three
Four
Five
Prescriber 1 Setup
*
Information
Prescriber Name
Prescriber Phone
Prescriber Fax
Prescriber Email
Prescriber NPI
Prescriber DEA
Prescriber 2 Setup
Information
Prescriber Name
Prescriber Phone
Prescriber Fax
Prescriber Email
Prescriber NPI
Prescriber DEA
Prescriber 3 Setup
Information
Prescriber Name
Prescriber Phone
Prescriber Fax
Prescriber Email
Prescriber NPI
Prescriber DEA
Prescriber 4 Setup
Information
Prescriber Name
Prescriber Phone
Prescriber Fax
Prescriber Email
Prescriber NPI
Prescriber DEA
Prescriber 5 Setup
Information
Prescriber Name
Prescriber Phone
Prescriber Fax
Prescriber Email
Prescriber NPI
Prescriber DEA
Practice Information
What Type of Prescribing do you prefer?
Pharmacy Portal
E-Scribe
Fax
Phone
Other
What Medications are you interested in? (Please include current price points if possible)
*
How much of each do you estimate you will order every month?
*
How soon do you plan to begin ordering?
*
Where did you hear about us? Name and Practice are greatly appreciated.
*
What specific current challenges or needs bring you us and how can we help you to best service your patients and practice?
What pharmacy are you currently using?
What are the best days and times to contact you?
Submit
Should be Empty: