New Business Development - Intake Form, Eagle

New Account Intake Form - EAGLE

Please ensure that a separate form is completed for each practice location, and note that only medical practice staff are authorized to complete this form. If you have any questions about onboarding or this form, please email Sales@revcustomrx.com.
Medical Provider Information
Principal Healthcare Provider (Account Holder)

First NameLast Name
Principal Healthcare Provider
Principal Healthcare Provider Email
example@example.com
Principal Healthcare Provider NPI #
Principal Healthcare Provider DEA#
Practice Name
Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Practice Website
Eagle Representative (If not listed, use field below)
Eagle Representative - Other
Practice Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
List of Current Licensed Medical Provider Staff (MD, DO, PA, NP, etc.)
Billing Contact Information

The designated billing contact should be an employee affiliated with the practice, as this individual will be responsible for supplying pertinent billing information for the practice.
Billing Contact Name

First NameLast Name
Billing Contact Email
example@example.com
Billing Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please enter billing address, if different from practice or shipping address
Is this a cell phone number?
If this is a cellphone number, does Eagle Pharma have permission to text message this number?
Preferred Method of Payment
Shipping Contact Information

The shipping contact should be an internal member of your practice, as this individual will be the recipient of tracking information corresponding to each order placed.
Shipping Contact Name

First NameLast Name
Shipping Contact Email
example@example.com
Shipping Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is this a cell phone number?
If this is a cellphone number, does Eagle Pharma have permission to text message this number?
Multiple Ship to Address - It must match the State and DEA license registration address(es).
Ordering Manager Contact Information

The ordering manager contact should be an internal member of your practice who will be placing the orders and managing the inventory.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is this a cell phone?
Can we text you about orders?
By signing this form, I hereby confirm that the medical practice I represent assumes fiscal accountability for all products ordered.
Signature
Please confirm the provider listed on the DEA registration maintains a regular presence on-site at the office. Confirmation is required for all controlled substance orders.
Form Completed By

First NameLast Name
Practice Role
Today's Date

MonthDayYear
Date
State Medical License and DEA License (if ordering controlled substances) - The principal healthcare provider is obligated to provide a copy of their State Medical and Drug Enforcement Administration (DEA) License.

Cancelof
DEA Location Verification (if ordering controlled substances) - Please upload photographs, not digital images obtained from internet searches, of the practitioner's DEA registered practice location where controlled substances will be routinely administered or dispensed.

Cancelof
Should be Empty:

New Account Intake Form - EAGLE

Medical Provider Information

Billing Contact Information

Shipping Contact Information

Ordering Manager Contact Information