NEW MEDICAL PRACTICE - EVERWELL
ACCOUNT INFORMATION
PRACTICE INFORMATION
Business Name
*
Phone Number
Please enter a valid phone number.
Business/Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Website
Primary Therapeutic Area of Interest
*
Please Select
Allergy
Animal Health
Anti-Infective/Wound Care
Functional Medicine
GI/Colorectal
Hormone Replacement
Hospice/Long Term Care/Hospital
Infectious Disease
IV Nutrition
OB/Gyn (non-hormone)
Oncology
Opthalmic
Otic
Pain Management
Respiratory(non-infectious disease)
Skin Care(Dermatology,Cosmeceuticals,hairloss)
Specialty Commerical Medications
Urology(non-hormone)
Weight Loss
Other Primary Therapeutic Area(s) of Interest
Men's Health
Women's Health
IV/IM Nutrition
Weight management
Skin: Dermatology/ Cosmeceutical
Functional Medicine
Allergy Immunotherapy
Urology
Hormone Replacement Therapy
Pain Management
Opthalmology/Otolaryngology
Gastroenterology/Colorectal
Business Partnership
Other
Primary Contact
*
First Name
Last Name
Preferred Method of Contact
*
Please Select
Cell Phone
Office Phone
Email
Primary Contact Email
*
example@example.com
Primary Contact Phone
Please enter a valid phone number.
Shipping Contact Name
First Name
Last Name
Shipping Contact Email
*
example@example.com
Days and Hour of Operation
*
Primary Payor
*
Office
Patient
Both
Billing Information
In an effort to protect your security, we do not collect credit card information online. A representative from Everwell Specialty Pharmacy will contact the designated billing contact to collect credit card information with 24-48 business hours after receipt. If you need to make changes to your billing contact or credit card on file, please contact the pharmacy direct at (855)507-2560.
Name of Person Responsible for Billing
*
Phone Number to Contact for Billing
*
Please enter a valid phone number.
Email Address of Person Responsible for Billing
*
example@example.com
How Did You Hear About Us?
Conference(Please Write Which Conference in the "Other" Field
Referral(Please Write Who Referred You in the "Other" Field)
Newsletter/Email
Salesperson's(Please Write the Salesperson's Name in the "Other"Field
Search Engine/Social Media/Website/Blog
Other
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Printed Name
*
First Name
Last Name
Job Title
*
Please verify that you are human
*
Continue
Continue
Should be Empty: