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Authorized Provider Application

About eight minutes. Have your state licence number and expiry, your NPI, and — only if you intend to order items that require it — your DEA registration. We do not ask for your Tax ID, Social Security number, or any card or bank details on this form.

Provider application

Every field marked with an asterisk is required. Your licence and DEA uploads are stored privately and reviewed by Provider Relations only.

1Practice

2Prescriber

3Shipping

4Locations

5Billing

6Sign

This takes about 8 minutes. Have to hand: your state medical license number and expiry, your NPI, and — only if you intend to order items that require it — your DEA registration. You can upload a photo or PDF of each. We do not ask for your Tax ID, Social Security number or bank details on this form.

Legal business name(Required)

DBA / practice name patients see

Leave blank if it is the same as the legal name.

Practice website

Practice type(Required)

Primary billing address(Required)

Street Address Address Line 2 City State ZIP Code

Practice main phone(Required)

Practice fax

Primary contact — full name(Required)

First Last

Primary contact role(Required)

For example: Practice Manager, Office Administrator, Physician.

Primary contact email(Required)

Best way to reach you

Phone

Either is fine

Ship to the billing address above?(Required)

Yes, same address

No, ship somewhere else

Primary shipping address

Street Address Address Line 2 City State ZIP Code

Receiving contact name(Required)

Receiving phone(Required)

Email for tracking notifications

Days you can receive deliveries(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Delivery window(Required)

Receiving instructions

Loading dock, suite number, who to ask for, anything the courier needs to know.

Do you order for more than one location?(Required)

No, one location

Yes, multiple locations

Additional location 1

Location 1 — name

Location 1 — shipping address

Street Address Address Line 2 City State ZIP Code

Location 1 — phone

Location 1 — contact email

Additional location 2

Leave blank if you do not have one.

Location 2 — name

Location 2 — shipping address

Street Address Address Line 2 City State ZIP Code

Location 2 — phone

Location 2 — contact email

Additional location 3

Leave blank if you do not have one.

Location 3 — name

Location 3 — shipping address

Street Address Address Line 2 City State ZIP Code

Location 3 — phone

Location 3 — contact email

Paying for orders

We do not collect card or bank details on this form. Once your application is approved you will complete a payment authorization — by card or by ACH — and return it on a private channel rather than through the website.

Both forms are available now on the Resources page if you would like to prepare them in advance. Return signed forms by fax to 847.806.0464, or call +1 (630) 768-6784 to arrange a secure alternative. Please do not send card numbers or bank account details by email.