Client Services Forms "*" indicates required fields Step 1 Basic Contact Information Tell us who you areName of Pharmacy* Contact Name* Email* Phone*FaxBusiness Hours Website Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Step 2 Please check up to 8 topics for your next production Feel free to use the additional comments section for any additional changes.Compounding & Wellness BHRT – General BHRT – Female BHRT – Male BHRT – Consults BHRT – Consults by Appt. Thyroid Saliva Test Kits Adrenal – General Adrenal – Dr. Wilson’s Original Formula® Fertility Meds Veterinary – All Veterinary – Compounding Veterinary – Flavoring Veterinary – Sterile Vet Meds Veterinary – Topicals Pain – General Pain – Fast Acting Pain Meds Pain – Slow Acting Pain Meds Pain – Shingles Creams & Gels Pain – Sports Meds Pain – Topical NSAIDS Pain – Trigger Point Pain Therapy Vitamins & Supplements – General Vitamins & Supplements – Co-Q-10 Vitamins & Supplements – Elderberry Vitamins & Supplements – Multi-Vitamin Vitamins & Supplements – Private Label Supplement Vitamins & Supplements – Vitamin B Complex Vitamins & Supplements – Vitamin B-12 Vitamins & Supplements – Vitamin C Vitamins & Supplements – Vitamin D Vitamins & Supplements – Vitamins for Flu Vitamins & Supplements – Zinc WW – ALA 300 Alpha Lipoic Acid WW – Alcohol Detox WW – Aller-Calm WW – Berberine Support WW – BioDIM Plus WW – Bone Health Support WW – Brain Health Support WW – Buffered Vitamin C 1000 mg WW – Children’s Acidophilus WW – Children’s Chewable Multivitamin w/ Acidophilus WW – Crave Control WW – Curcumin Complex WW – Diabetes Balance WW – Digestive Enzymes with Betaine WW – Flax Seed Oil 1000 mg WW – Glucosamine Sulfate WW – Gluten Digestive Enzyme WW – GABA Calm WW – Green Tea-70 High Concentration EGCg WW – Gut Restorative PRP WW – Immune Daily Support WW – InflamMove WW – L-Glutathoine Reduced WW – Libido Health for Men and Women WW – Liposomal Glutathione WW – Magnesium Chelate 400 mg WW – Marine Fish Oil 1000 mg WW – Memory Plus WW – Black Cohosh Plus 40 mg WW – Methyl B-12 Drops WW – Methyl B-12 Lozenges 3000 mg WW – Nitric Oxide Formula WW – Omega Max WW – Omega-3 Fish Oil Enteric Coated (HP) WW – Perfect Protein Powder WW – Phosphatidyl Serine Complex 500 mg WW – Pycnogenol 50 mg WW – Sleep Perfect Formula WW – Sleep Support WW – SporeBiotic Max WW – Thyroid Support with Zinc WW – UT Support WW – Zinc, Elderberry & D Lozenges Ortho Molecular® – D-Hist Ortho Molecular® – Sunscreen Ortho Molecular® – Vitamins – General Ortho Molecular® – Vitamins – CollaGEN Ortho Molecular® – Vitamins – CopaCalm Ortho Molecular® – Vitamins – Lipitrol OX Ortho Molecular® – Vitamins – Liquid Vitamin D3 Ortho Molecular® – Vitamins – NuAdapt Ortho Molecular® – Vitamins – Ortho B Complex Ortho Molecular® – Vitamins – Ortho Biotic Ortho Molecular® – Vitamins – OrthoMune Ortho Molecular® – Vitamins – Turiva Ortho Molecular® – Vitamins – Viracid Compounding & Wellness (cont.) Standard Process® New Chapter Natural Creations® Solutions Rx XYMOGEN® Thorne Supplements Integrative Therapeutics Statinzyme® Fish Oils – General Fish Oils – Carlson Oils® Fish Oils – Nordic Naturals® Fish Oils – Ocean Blue Autoimmune Disease Vitamin B-12 Injections Metabolic Code Anti-Nausea Gels – General Anti-Nausea Gels – Adult Anti-Nausea Gels – Pediatrics Flavored Suspensions – General Flavored Suspensions – Adult Flavored Suspensions – Pediatrics Flavored Troches – General Flavored Troches – Adult Flavored Troches – Pediatrics Rx Skin Therapy® Sterile Sterile Injectables Ophthalmic – General Ophthalmic – Autogolous ACHC Accredited General Compounding Hospice Meds Oral Health – General Oral Health – For Cancer Patients Allergy Nasal Sprays Nasal Irrigation NASONEB® Authorized Dealer Discontinued Meds PCCA Member PCCA – Atrevis Hydrogel® PCCA – Lipoderm® Topical PCCA – Mucolox® PCCA – Pracasil Plus® PCCA – RDT-Plus® PCCA – Spira-Wash Gel® PCCA – SuspendIt Anhydrous® PCCA – Synapsin® PCCA – Versabase Cream® PCCA – XemaTop® PCCA – ZoSil® ED – Non-Specific ED – Bi-Mix/Tri-Mix ED – Bi/Tri/Quad/Super Quad-Mix ED – Compounded Sildenafil ED – Compounded Tadalafil Podiatry Wound Care Dermatology – General Nutrient Depletion Takes Rx Insurance on Compounds Dry Eye Rx HCG Low Dose Naltrexone® Ultra Low Dose Naltrexone® Bio-View Facial Scan HBA1C Screening Cholesterol Screenings Neuroscience™ Metabolic Syndrome Hemorrhoids Naloxone Specialty Pharmacy Services CBD – General CBD – General – Zero THC CBD – Ananda CBD – Charlotte’s Web CBD – CV Sciences CBD – Green Roads CBD – Imbue Botanicals Consults for Wellness Consults for Weight Mgmt. USP 797 Compliant USP 800 Compliant USP 1151 Compliant Meds for Autism Lollipops – General Lollipops – Nicotine Lollipops – Pain Lollipops – Pediatrics Retail Pharmacy or Hybrid FLAVORx® Probiotics Wellness Classes – General Wellness Classes – Asthma Wellness Classes – Diabetes Wellness Classes – High Blood Pressure Wellness Classes – High Cholesterol Wellness Classes – Smoking Cessation Wellness Classes – Weight Loss Weight Loss Ideal Protein® Diet CofixRx COVID-19 – Protocols COVID-19 – Supplies COVID-19 – Rapid Antibody Testing COVID-19 – Antigen Testing COVID-19 – PCR Testing COVID-19 – Drive-thru Testing COVID-19 – Vaccines – Johnson & Johnson COVID-19 – Vaccines – Moderna COVID-19 – Vaccines – Pfizer COVID-19 – Boosters Flu & Strep Test Immunizations – All Immunizations – Flu Immunizations – Shingles Shingrix® Travel Vaccines – General Travel Vaccines – Good Neighbor Pharmacy Travel Vaccines – Independent Pharmacy Tele-Pharmacy Medication Compliance Pkg. Medicine On Time Dispill Med Sync Simplify My Meds SYNC-RX Medication Therapy Mgmt. Wellevate Email Alerts for Rx Pick Up Text Alerts for Rx Pick Up Local Delivery – Fee Based Local Delivery – Free Drive-Thru Window Head Lice Kid’s Club Free Vitamins Online Refills Generic Rx Savings Program BioFreeze Aromatherapy – General Aromatherapy – doTERRA® Aromatherapy – NOW® Aromatherapy – Young Living® Proton Pump Inhibators Summer Care Zan-fel Know Your Pharmacist General Retail Pharmacy Candy, Cards, Gifts, etc. DME DME – General Wheel Chairs Scooters Canes Quad Canes Rollator Walkers Hospital-Style Beds Seat-Lift Chairs Shower Benches Incontinence Supplies Nebulizers & Neb. Meds. Home Oxygen Concentrator Portable Oxygen In-Home Oxygen CPAP – Machines (CPAP or BiPAP) CPAP – Mask, Tubing, & Filters CPAP – SoClean® Respiratory Therapist on Staff Infusion Equipment Athletic Braces & Supports Incrediware Diabetes – General Diabetes – Education Classes Diabetes – Testing Supplies Diabetic Shoes – General Diabetic Shoes – Dr. Comfort Diabetic Shoes Compression Hosiery Sockwell Socks Ostomy Supplies Wound Care Supplies Mobile App – General Mobile App – Pocket Rx Mobile App – Refill Assistant Mobile App – Refill Rx Mobile App – Rx 2 Go Mobile App – RxMobility® Accepts Medicare “D” Pharmacist name(s) for this message Additional CommentsPlease also use this space to list core values and featured productsStep 3 (Optional) Create or Update My Pharmacy ServicesI Need to Update My Pharmacy Profile Click Here to create or update my pharmacy services Please tell us about your pharmacy services using the checkboxes below. Check ALL that apply. To help us serve you better, please check every service you currently offer.Compounding & Wellness BHRT – General BHRT – Female BHRT – Male BHRT – Consults BHRT – Consults by Appt. Thyroid Saliva Test Kits Adrenal – General Adrenal – Dr. Wilson’s Original Formula® Fertility Meds Veterinary – All Veterinary – Compounding Veterinary – Flavoring Veterinary – Sterile Vet Meds Veterinary – Topicals Pain – General Pain – Fast Acting Pain Meds Pain – Slow Acting Pain Meds Pain – Shingles Creams & Gels Pain – Sports Meds Pain – Topical NSAIDS Pain – Trigger Point Pain Therapy Vitamins & Supplements – General Vitamins & Supplements – Co-Q-10 Vitamins & Supplements – Elderberry Vitamins & Supplements – Multi-Vitamin Vitamins & Supplements – Private Label Supplement Vitamins & Supplements – Vitamin B Complex Vitamins & Supplements – Vitamin B-12 Vitamins & Supplements – Vitamin C Vitamins & Supplements – Vitamin D Vitamins & Supplements – Vitamins for Flu Vitamins & Supplements – Zinc WW – ALA 300 Alpha Lipoic Acid WW – Alcohol Detox WW – Aller-Calm WW – Berberine Support WW – BioDIM Plus WW – Bone Health Support WW – Brain Health Support WW – Buffered Vitamin C 1000 mg WW – Children’s Acidophilus WW – Children’s Chewable Multivitamin w/ Acidophilus WW – Crave Control WW – Curcumin Complex WW – Diabetes Balance WW – Digestive Enzymes with Betaine WW – Flax Seed Oil 1000 mg WW – Glucosamine Sulfate WW – Gluten Digestive Enzyme WW – GABA Calm WW – Green Tea-70 High Concentration EGCg WW – Gut Restorative PRP WW – Immune Daily Support WW – InflamMove WW – L-Glutathoine Reduced WW – Libido Health for Men and Women WW – Liposomal Glutathione WW – Magnesium Chelate 400 mg WW – Marine Fish Oil 1000 mg WW – Memory Plus WW – Black Cohosh Plus 40 mg WW – Methyl B-12 Drops WW – Methyl B-12 Lozenges 3000 mg WW – Nitric Oxide Formula WW – Omega Max WW – Omega-3 Fish Oil Enteric Coated (HP) WW – Perfect Protein Powder WW – Phosphatidyl Serine Complex 500 mg WW – Pycnogenol 50 mg WW – Sleep Perfect Formula WW – Sleep Support WW – SporeBiotic Max WW – Thyroid Support with Zinc WW – UT Support WW – Zinc, Elderberry & D Lozenges Ortho Molecular® – D-Hist Ortho Molecular® – Sunscreen Ortho Molecular® – Vitamins – General Ortho Molecular® – Vitamins – CollaGEN Ortho Molecular® – Vitamins – CopaCalm Ortho Molecular® – Vitamins – Lipitrol OX Ortho Molecular® – Vitamins – Liquid Vitamin D3 Ortho Molecular® – Vitamins – NuAdapt Ortho Molecular® – Vitamins – Ortho B Complex Ortho Molecular® – Vitamins – Ortho Biotic Ortho Molecular® – Vitamins – OrthoMune Ortho Molecular® – Vitamins – Turiva Ortho Molecular® – Vitamins – Viracid Compounding & Wellness (cont.) Standard Process® New Chapter Natural Creations® Solutions Rx XYMOGEN® Thorne Supplements Integrative Therapeutics Statinzyme® Fish Oils – General Fish Oils – Carlson Oils® Fish Oils – Nordic Naturals® Fish Oils – Ocean Blue Autoimmune Disease Vitamin B-12 Injections Metabolic Code Anti-Nausea Gels – General Anti-Nausea Gels – Adult Anti-Nausea Gels – Pediatrics Flavored Suspensions – General Flavored Suspensions – Adult Flavored Suspensions – Pediatrics Flavored Troches – General Flavored Troches – Adult Flavored Troches – Pediatrics Rx Skin Therapy® Sterile Sterile Injectables Ophthalmics – General Ophthalmics – Autogolous ACHC Accredited General Compounding Hospice Meds Oral Health – General Oral Health – For Cancer Patients Allergy Nasal Sprays Nasal Irrigation NASONEB® Authorized Dealer Discontinued Meds PCCA Member PCCA – Atrevis Hydrogel® PCCA – Lipoderm® Topical PCCA – Mucolox® PCCA – Pracasil Plus® PCCA – RDT-Plus® PCCA – Spira-Wash Gel® PCCA – SuspendIt Anhydrous® PCCA – Synapsin® PCCA – Versabase Cream® PCCA – XemaTop® PCCA – ZoSil® ED – Non-Specific ED – Bi-Mix/Tri-Mix ED – Bi/Tri/Quad/Super Quad-Mix ED – Compounded Sildenafil ED – Compounded Tadalafil Podiatry Wound Care Dermatology – General Nutrient Depletion Takes Rx Insurance on Compounds Dry Eye Rx HCG Low Dose Naltrexone® Ultra Low Dose Naltrexone® Bio-View Facial Scan HBA1C Screening Cholesterol Screenings Neuroscience™ Metabolic Syndrome Hemorrhoids Naloxone Specialty Pharmacy Services CBD – General CBD – General – Zero THC CBD – Ananda CBD – Charlotte’s Web CBD – CV Sciences CBD – Green Roads CBD – Imbue Botanicals Consults for Wellness Consults for Weight Mgmt. USP 797 Compliant USP 800 Compliant USP 1151 Compliant Meds for Autism Lollipops – General Lollipops – Nicotine Lollipops – Pain Lollipops – Pediatrics Retail Pharmacy or Hybrid FLAVORx® Probiotics Wellness Classes – General Wellness Classes – Asthma Wellness Classes – Diabetes Wellness Classes – High Blood Pressure Wellness Classes – High Cholesterol Wellness Classes – Smoking Cessation Wellness Classes – Weight Loss Weight Loss Ideal Protein® Diet CofixRx COVID-19 – Protocols COVID-19 – Supplies COVID-19 – Rapid Antibody Testing COVID-19 – Antigen Testing COVID-19 – PCR Testing COVID-19 – Drive-thru Testing COVID-19 – Vaccines – Johnson & Johnson COVID-19 – Vaccines – Moderna COVID-19 – Vaccines – Pfizer COVID-19 – Boosters Flu & Strep Test Immunizations – All Immunizations – Flu Immunizations – Shingles Shingrix® Travel Vaccines – General Travel Vaccines – Good Neighbor Pharmacy Travel Vaccines – Independent Pharmacy Tele-Pharmacy Medication Compliance Pkg. Medicine On Time Dispill Med Sync Simplify My Meds SYNC-RX Medication Therapy Mgmt. Wellevate Email Alerts for Rx Pick Up Text Alerts for Rx Pick Up Local Delivery – Fee Based Local Delivery – Free Drive-Thru Window Head Lice Kid’s Club Free Vitamins Online Refills Generic Rx Savings Program BioFreeze Aromatherapy – General Aromatherapy – doTERRA® Aromatherapy – NOW® Aromatherapy – Young Living® Proton Pump Inhibators Summer Care Zan-fel Know Your Pharmacist General Retail Pharmacy Candy, Cards, Gifts, etc. DME DME – General Wheel Chairs Scooters Canes Quad Canes Rollator Walkers Hospital-Style Beds Seat-Lift Chairs Shower Benches Incontinence Supplies Nebulizers & Neb. Meds. Home Oxygen Concentrator Portable Oxygen In-Home Oxygen CPAP – Machines (CPAP or BiPAP) CPAP – Mask, Tubing, & Filters CPAP – SoClean® Respiratory Therapist on Staff Infusion Equipment Athletic Braces & Supports Incrediware Diabetes – General Diabetes – Education Classes Diabetes – Testing Supplies Diabetic Shoes – General Diabetic Shoes – Dr. Comfort Diabetic Shoes Compression Hosiery Sockwell Socks Ostomy Supplies Wound Care Supplies Mobile App – General Mobile App – Pocket Rx Mobile App – Refill Assistant Mobile App – Refill Rx Mobile App – Rx 2 Go Mobile App – RxMobility® Accepts Medicare “D” Do you accept insurance on compounded prescriptions?*Do you accept insurance on compounded prescriptions? Yes No CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
