NEW MEDICAL PRACTICE

BILLING INFORMATION
In an effort to protect your security we do not collect credit card information online at this time. A representative from Stanley Specialty Pharmacy will contact the designated billing contact to collect credit card information within 24- 48 business hours after receipt of this form. If you need to make changes to your billing contact or credit card on file, please contact the pharmacy directly at (704) 370-6612 or toll-free (866) 698-0247.
Primary Payor*

OfficePatientBoth
Person Responsible for Billing

First NameLast Name
Phone Number to Contact for Billing

First NameLast Name
Email Address of Person Responsible for Billing
example@example.com

SIGNATURE AND OTHER INFORMATION
How did you hear about Stanley Specialty Pharmacy?*

Conference (Please tell us which conference in the field below)Referral (Please write who referred you in the field below)Newsletter / EmailSalesperson (Please tell us salesperson's name in the field below)Search Engine / Social Media / Website / Blog
Conference Name
Referral (name of person or office)
Salesperson's Name
Signature*

Clear
Today's Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
Job Title*
Please verify that you are human*
Should be Empty:

NEW MEDICAL PRACTICE - STANLEY