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:

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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 *