Location Information Form

Please complete the information below:
* Required Field

Please fill in all required fields.

Facility Type: If Other:

* Your E-mail Address:

What is the exact shipping address of your facility?

* Shipping Address (with Suite #):
* Shipping City:
* Shipping State:
* Shipping Zip:

Complete Section 2 below only if you will be participating in contracts for pharmaceuticals.

If physician office/clinic:
Who is the physician that you would like rostered?
(Note: The DEA certificate for the rostered physician must exactly match the shipping address of the facility.)

Primary Provider First Name
Primary Provider Last Name
Federal DEA Certificate Number

Tell us about your clinic facility and who will place orders.
(Note: Organization Legal Name must be the exact name associated with the Federal Tax ID. Discrepancies will cause delays in the rostering process.)

* Organization Legal Name
* Doing Business as Name
* Facility Phone
* Purchasing Contact Name (First & Last)
* Purchasing Contact Title
* Purchasing Contact Phone
Purchasing Contact Fax
* Purchasing Contact E-mail
* Which distributor will you be using?

Tell us about your organization
and who can sign legal agreements.

Name of Corporate Owner (or none)
COID Number
* Authorized Signee Name
* Authorized Signee E-mail

Additional Information

* What organization referred you to us?
At which hospital(s) do you practice?
Anything else we need to know?

Submit this request to us and we will send an agreement package to you for review. This request does not commit you to the program in any way. Only after you sign and return the agreements can we begin the enrollment process.