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Registration Form

Account Registration Form

YOU MAY SEND YOUR FIRST ORDER IMMEDIATELY AFTER YOU HAVE SUBMITTED THIS FORM. PLEASE NOTE, PAYMENT INFORMATION (CREDIT CARD) WILL BE REQUIRED IN ORDER FOR US TO PROCESS YOUR ORDER.

Your Name

Business Phone

Do you have a representative?

First Name

Last Name

Business Website URL

Provider Information

Provider Name

Clinic Name

DEA Number

Medical License Number

NPI Number

Cell Number

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

First Name

Last Name

Primary Email

Office Phone Number

Fax Number

Please provide any additional comments or information here

Billing Information

Cardholder First Name

Cardholder Last Name

Card Type

Visa

Mastercard

American Express

Discover

Card Number

Expiration Date (mo/yr)

CVV Code

Address

Address Line 1

Address Line 2

City

State

Zip Code

Text Input

(Please Initial) I hereby authorize DPR Pharmacy to charge the above credit card through their online credit card processing system for all physicians affiliated with this practice. The card holder specified above agrees that DPR Pharmacy will automatically bill the subscriber’s credit card upon completion of the prescription order unless other arrangements have been made specific to the above subscriber’s account.

Prescription Guidelines

Please read through our prescription guidelines carefully. Here you will find information on how to correctly write prescriptions to avoid any delays in processing.

Check each box when guideline has been read.

PATIENT INFORMATION - DPR Pharmacy Retail & Compound Pharmacy is a 503A pharmacy. Each prescription must be written under a patient's name. Office stock prescriptions are not accepted. Make sure ALL patient demographics are listed on the prescription.

DOSING INSTRUCTIONS - Dosing instructions must be written for each individual prescribed medication. Amount, frequency, dilution, injection type, max dose, etc. Dosing instructions must not exceed a 6 month period.

QUANTITY - Quantity must be written for each medication prescribed. Make sure you write how many vials, capsules, troches, or grams of cream for each medication

CLARIFICATIONS - If a prescription is missing any information & clarifications are needed, your order may be delayed.

Registration Packet

The above form must be completely filled out and licenses must be sent in before your first order can be processed.

Please upload your licenses here.

PRESCRIBER LICENSE Please fax in your medical provider license. ie. MD, DO, FNP, NP, PA, etc.

Choose File

DEA LICENSE If ordering any controls, a DEA License must be sent in.

Choose File

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Email Address

Phone Number

Our Location

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Account Registration Form

Provider Information

Billing Information

Prescription Guidelines

Registration Packet

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