ESCP New Medical Practice

New Medical Practice

Account Information
Practice Information
Business Name*
Business Phone Number*
Please enter a valid telephone number
Business Fax Number*
Please enter a valid fax number
Business/ Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Website
Primary Therapeutic Area of Interest:*
Other Therapeutic Area(s) of Interest:

Men's HealthWomen's HealthHormonesSkin: Dermatology / CosmeceuticalIV/IM NutritionWeight ManagementFunctional MedicineAllergy ImmunotherapyUrologyHormone Replacement TherapyPain ManagementOphthalmology / OtolaryngologyGastroenterology / ColorectalBusiness Partnership
Primary Contact*

First NameLast Name
Preferred Method of Contact*
Telephone/Fax/Email
Primary Contact Email*
Primary Contact Phone Number*
Please enter a valid phone number.
Shipping Contact Name

First NameLast Name
Shipping Contact Email
example@example.com
Days/Hours of Operation:
Primary Payor:*

OfficePatientBoth
Billing Information:
In an effort to protect your security, we do not collect credit card information online. A representative from Eastern States 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 (800) 964-0094.
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" FieldReferral (Please Write Who Referred You in the "Other" Field)Newsletter / EmailSalesperson (Please Write the Salesperson's Name in the "Other" Field)Search Engine / Social Media / Website / BlogOther
Signature*

Clear
Printed Name*

First NameLast Name
Job Title*
Today's Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

New Medical Practice

Practice Information