Provider Script Form Request
Complete this form to set up your prescriber profile in our systems and to request one of our custom prescription forms. Please note: We do not make: peptides, IV nutrients or vitamins, growth hormones, tirzepatide, semaglutide, or other weight loss compounds.
Name
*
First Name
Last Name
NPI#
*
Which states do your patients reside in?
Phone Number
*
Please enter a valid phone number.
Provider or practice general email
*
example@example.com
Fax #
DEA# (if applicable)
Practice/Business Name
*
Practice/Business Address (main)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which Script form(s) are you looking for?
*
Atropine
BHRT
Colorectal
Dermatology
ENT
Family Practice
Gastrointestinal
Magic Mouthwash / Dentistry
OBGYN
Pain Specialists
Pediatric
Physical Therapy
Podiatry
Other
If you selected "Other," please let us know how we can help.
How did you hear about us?
Ad
Conference
Family/Friend
Google
Physician Referral
Social Media
Website
Other
If you selected "other," please let us know!
Submit
Should be Empty: