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.
Doctor Name
*
First Name
Last Name
Requester Name
First Name
Last Name
Provider NPI#
*
NPI# provided must be valid
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!
If you found us online, what did you type into the search engine to find us?
Submit
Should be Empty: