New Medical Practice
ACCOUNT INFORMATION - Please complete one account form per location.
PRACTICE INFORMATION
Business Name
*
Business Phone Number
*
Please enter a valid phone number.
Business Fax Number
*
Please enter a valid phone number.
Business Website
Business/Shipping Address*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sales Representative
*
Please Select
Unknown
Other
Larry Woodhouse
Sue James
DJ Duarte
Richard Williams
Pete Andrich
Primary Therapeutic Interest
*
Please Select
Animal Health
Allergy / Immunotherapy
Anti-Infective / Wound Care
GI / Colorectal
Hormone Replacement
Hospice / Long Term Care / Hospital
Infectious Disease
IV Nutrition
Functional Medicine
OB/GYN (non-hormone)
Oncology
Opthalmic
Otic
Pain Management
Respiratory (non-infectious disease)
Skin Care (Dermatology / Cosmeceutical)
Specialty Commercial Medications
Urology (non-hormone)
Weight Loss
Other Therapeutic Interest
Animal Health
Allergy / Immunotherapy
Anti-Infective / Wound Care
GI / Colorectal
Hormone Replacement
Hospice / Long Term Care / Hospital
Infectious Disease
IV Nutrition
Functional Medicine
OB/GYN (non-hormone)
Oncology
Opthalmic
Otic
Pain Management
Respiratory (non-infectious disease)
Skin Care (Dermatology / Cosmeceutical)
Specialty Commercial Medications
Urology (non-hormone)
Weight Loss
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 - Office Phone
*
Please enter a valid phone number.
Primary Contact - Cell Phone
Please enter a valid phone number.
Shipping Contact Name
*
First Name
Last Name
Shipping Email
*
example@example.com
Days and Hours of Operation
*
Primary Payor
*
Practice
Patient
Both
Billing Information
In an effort to protect your security, we do not collect credit card information online. A representative from Lee Silsby Compounding Pharmacy will contact the designated billing contact to collect credit card information within 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 1-800-918-8831.
Billing Contact
*
First Name
Last Name
Billing Contact Email
*
example@example.com
Billing Phone Number
*
Please enter a valid phone number.
How did you hear about us?
Conference
Referral
Newsletter / Email
Salesperson
Search Engine / Social Media / Website / Blog
Other
Signature
*
Print Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Submit
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