Provider Website Script Form Request

Provider Registration & Script Form Request

Complete this form to set up your prescriber profile in our systems and to request a custom prescription form. If you are registering more than one Doctor/Provider in your practice, you must submit this form for each individual. Please note: We do not make: peptides, IV nutrients or vitamins, growth hormones, tirzepatide, semaglutide, or other weight loss compounds.
Doctor/Provider Name*

First NameLast Name
Requester Name

First NameLast Name
Doctor/Provider NPI#*
NPI# provided must be valid
DEA# (if applicable)
List all states of active medical licensure.
We will look up your medical license number(s) to save you some time.
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid fax number.
Provider/Doctor Email Address
example@example.com
Practice General Email Address*
example@example.com
Authorization to Receive Faxed and/or Email Communications from Valor Compounding Pharmacy

To improve the efficiency of communication with your office, Valor Compounding Pharmacy may send important updates, formulary information, clinical resources, prescription forms, and operational notices by fax and/or email.

Federal and/or state regulations require that we obtain your permission to send faxed or emailed communications that may include educational or promotional information about our services.

By completing the form below, you authorize Valor Compounding Pharmacy to send information to the fax number you provide. You may revoke this authorization at any time. Opt-Out: Your office may opt out of any communication channel at any time by contacting the pharmacy's main line at 510-548-8777 or by emailing our Communications team at marketing@vcprx.com.

Please note: Communications related to specific prescriptions, patient orders, or continuity-of-care needs do not require this authorization. Valor Compounding Pharmacy may contact your practice by fax, email, or phone as needed to support patient care and ensure timely fulfillment of medication orders.
Fax Communications Authorization*

YES, our office authorizes Valor Compounding Pharmacy to send faxed communications to the fax number provided.NO, our office does not wish to receive faxed communications.
Email Communications Authorization*

YES, our office authorizes Valor Compounding Pharmacy to send emailed communications to the email address(es) provided.NO, our office does not wish to receive email communications.
Practice/Business Name*
Practice/Business Address (Main)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Script form(s) would you like to request?*

AtropineBHRTColorectalDermatologyENTFamily PracticeFertilityGastrointestinalMagic Mouthwash / DentistryOBGYNPain SpecialistsPediatricPhysical TherapyPodiatryUrologyVeterinaryOther
If you selected "Other," please let us know how we can help.
Estimated number of compound prescriptions prescribed per week.*
How did you hear about us?*

Family/FriendSocial MediaPhysician ReferralAdvertisementPatient ReferralConferenceGoogle or Internet SearchValor WebsiteOther
If you selected "other," please let us know how you heard about us.
If you found us online, what did you type into the search engine to find us?
utm_campaign
utm_medium
utm_source
HubSpot Pipeline
Fax # OLD
Should be Empty:

Provider Registration & Script Form Request