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Prescriber Name
*
Phone
*
Specialty
*
Dentistry
Dermatology
ENT/Allergy
Family Practice
Medspa
Gastroenterology
Ob/Gyn
Oncology
Ophthalmology
Orthopedics
Pediatrics
Podiatry
Urology
Veterinary
Other
Please List
Practice Name
*
Job Title/Position
*
FAX
Medical Designation
*
Website URL
Email
*
NPI#
DEA#
Practice Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have a Supervising/Collaborating Physician?
Yes
No
Please enter your Supervising/Collaborating Physician's name, credentials and DEA#
Which of the following areas do you currently provide treatments for? Check all that apply.
Men's and Women's Health
Weight Management
Anti-Aging and Wellness
Peptide Therapy
Sexual Dysfunction
Bio-Identical Hormones
Dermatology / Cosmetology
Skin Lightening Topicals
Chemical Peels & Irritants
Hair Loss
Topical Numbing Creams
Acne/Eczema/Psoriasis
Other Services
Specialty Compounds
Pain Management
Podiatry Compounds
Pharmaceutical Grade Vitamins & Supplements
ENT/Ophthalmic/Dental
Veterinary Compounds
Are there other services not listed above you plan to add to your practice?
Yes
No
Please list.
Additional Comments
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