Account Setup Form – Grant Lisk – 618.241.9121

Facility Name: *

Facility Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Facility Phone Number: *

Facility Fax Number: *

Delivery Address if Different from Above:

Address Line 1

Address Line 2

City

State

Zip Code

Years In Business: *

Current Pharmacy Provider: *

Medical Director / Prescriber: *

First

Middle

Last

Medical Director Email: *

Prescriber Medical Title (MD, ARNP, etc) *

Prescriber NPI: *

Prescriber DEA (If None, Type N/A): *

Primary Contact: *

First

Last

Primary Contact Phone Number: *

Primary Contact Email: *

Secondary Contact:

First

Last

Secondary Contact Phone Number:

Secondary Contact Email:

If your would like to have your logo on your portal, please upload below.

Drag & Drop Files, Choose Files to Upload

By completing the Account Setup and Credit Card on File Authorization Forms, I hereby authorize RxCompoundStore.com, LLC to deliver all patient prescriptions to the listed facility delivery address with all related charges billed to the credit card on file. The facility assumes the responsibility of delivering the medications to the patient and independently collecting any monies due to the facility for such services including the facility’s pre-payment of the medications. *

Clear Signature

Print Name of Signer: *

First

Middle

Last

Date *

CREDIT CARD ON FILE AUTHORIZATION FORM

Card Type: *

Visa
Mastercard
American Express
Discover

Please list anyone other than the cardholder that is authorized to use this credit card.

I hereby authorize RxCompoundStore.com, LLC to charge the credit card listed above for the payment of all prescription orders. This credit card will be kept on file and will remain in effect until the expiration of the credit card account. Applicants may revoke this credit card on file by submitting a written request to the address at the top of this form. A new form must be submitted if any information such as credit card expirations or authorized users is changed. Applicants agree to pay the cost for any returned or challenged payments. *

Clear Signature

Print Signer's Name *

First

Middle

Last

Date of Signing *

How Did you Hear About us? *

Has a representative from our pharmacy reached out via email or telephone? *

Name on Card: *

Card Number: *

Expiration Date: *

CVV Code (Security Code): *

Billing Address: *

Address Line 1

Address Line 2

City

State

Zip Code