Wellness Clinics — New Account Setup Form

Wellness Clinics – New Account Setup Form

Prescriber Information

First Name *

Last Name *

NPI *

Credentials *

Practice Name *

Practice Address *

City *

State *

Zip *

Phone *

Email *

Billing Information

Use Practice Address as a Billing Address

Billing Address *

City *

State *

Zip *

Phone *

Email *

Shipping Address

Use Billing Address as a Shipping Address

Shipping Address *

City *

State *

Zip *

Phone *

Email *

Pharmacy / Physician License Number

Upload Business License

State License Number *

Upload State License *

DEA License Number

Upload DEA License

Payment Information

In order to place orders, a Credit Card will need to be setup in the 503B Portal which will be provided to you.

Prescriber & Pharmacy Agreement

All compounded preparations provided by Nivagen 503B may only be administered to the patient and may not be dispensed to the patient or sold to any other person or entity.
To include on a patient's chart, medication order or medication administration record the lot number and expiration date of the compounded preparation administered to the patient.
To inform patients to contact them directly in order to report any adverse reaction and/or complaint. That information will then be relayed to Nivagen 503B.
Acknowledges and represents that all information listed above is true.
Acknowledges and represents that your organization is legally able to order and solicit the services of Nivagen Pharmaceuticals.
To only use medication for patients with a medical need for compounded alternatives.

Company representative *

Date *