New Account Setup Form

Please fill out the form below

Thank you for selecting Wells Pharmacy Network for your compounding needs.
Your Wells Pharmacy Network Account Team is available to answer any questions you may have about the application. We look forward to serving you and your patients.

Office Information

Prescriber Name

DEA#

Physician State License#

Practice/Clinic Name

NPI#

Primary Location?

Does your State Board of Pharmacy/Medicine require a distribution license for testosterone?

If Yes, License Number. If No, N/A

Website

Phone

Fax

Address

City

State

Zip

Office Contact (if other than prescriber)

Phone

EMR System

Let us know if someone referred you to us, or N/A

Preparer’s Name

Date

Time

Preparer's Signature

*If applicable, please upload your physicians collaboration agreement here.

Choose File

Shipping Tracking Information

Credit Card Information

Billing same as shipping address?

CC Number

Exp

CVV

Zip

Address

City

State

Zip

Credit Card Owner

Phone

EMR System

Preparer’s Name

Date

Time

I authorize payment to be charged to my credit card, confirm that the information provided is true and accurate, and consent to the collection, use, and sharing of my information with authorized parties solely for the purpose of processing this transaction, in accordance with applicable privacy laws and the Privacy Policy.

Preparer's Signature

Inspections / Disciplinary Actions

List of Previous Inspections Regulatory Agency / Date

List of Disciplinary Actions taken against License in past 5 years

Are there any Disciplinary Actions pending?

Please summarize your current regulatory compliance status

Document submitted by:

Print Name

Position/Title

Date

Time

Preparer's Signature

Authorized Agents - ONLY NEEDED FOR 503B ORDERS

Please list all Authorized Agents of DEA License Holder. Only the individuals listed below will be authorized to place orders from our 503B facility. If you have multiple DEA licenses, you will need to fill out an Authorized Agent Information form per license.

Practice Name

Prescriber’s Name

DEA#

Does your State Board of Pharmacy/Medicine require a distribution license for testosterone?

If Yes, License Number. If No, N/A

Name

Note

What will you be ordering?

Prescriber’s Name

Date

Time

Preparer's Signature

Please Note: Any time you make a change to an Authorized Agent, you must resubmit this form. If you have multiple DEA licenses, please submit a separate form for each license. If you have any questions, contact your Account Sales Team or email info@wellsrx.com.

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New Account Setup Form