Please use this form for licensed medical providers to be allowed to purchase prescription pharmaceuticals.
- The provider must have a current active license with the authority to prescribe medications.
- We will only sell to providers, we do not sell medications to end users or customers with prescription.
- Sales are contingent upon state licensing restrictions and medication availability.
- The provider must be the one to sign this form and we require a copy of the license or DEA license. We cannot accept the online state board verification print out.
- This form allows us to ship medications to the facilities operating under the umbrella of the practitioner's license.
- Medications will be shipped with a signature required and may or may not have additional shipping fees.