Healthcare Provider Onboarding

Complete to begin your partnership with New Vitalis Pharmacy

New Vitalis Pharmacy does not provide office-use compounded products as we are designed by the FDA as a 503a pharmacy, which require patient-specific prescriptions before dispensing compounds.

Don't worry - our turnaround times are under 72 hours and we can still ship to clinics for patient use!

•••Please note that the individual filling out and signing this form must hold a valid medical license in each state in which you provide medical services, possesses the legal right to enter
into a binding agreement, and accepts without limitation conducting this transaction electronically, disclaimers of warranties, damage and remedy exclusions and limitations arbitration and choice of Kentucky law. Such individual represents and warrants that he or she has the authority to enter into and bind the Provider to the agreement terms.•••

Tell us about yourself

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From where or whom did you hear about us?*

Name*

First Last

Clinic Name*

Clinic Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Clinic Mobile Number*

Website*

Clinic Office Phone*

Clinic Email*

Medical Provider Information

Provider NPI*

Provider Type*

Supervising Doctor NPI Number(if applicable)

Additional Provider Names and NPIs

Terms and Conditions, Credit Card Authorization & Recurring Payments

Click here to view the terms and conditions.

Here’s How Recurring Payments Work:

You authorize New Vitalis to charge to your credit card when you submit an order for a prescription product with us. You will be charged the Product Price, plus all pass through shipping.

Recurring Credit Card Authorization

You may choose to have your prescription product orders automatically charged to your Visa, MasterCard, American Express, or Discover Card upon your submission of a prescription order to New Vitalis Pharmacy (“New Vitalis”) in your account.

You will have the opportunity to add your Credit Card information in your account when you send your first prescription, after that we will have it saved in your billing profile.

Credit Card Authorization*

I understand that New Vitalis Pharmacy requires payment via credit card prior to shipment of all product orders. I understand that I will have the option to make payment or require my patients to make payment upon my submission of product orders.

Terms and conditions*

I attest that I have read and agree to Terms and Conditions.

Today's Date*

With my signature below , I agree to the terms and conditions and pricing, and if applicable, credit card authorization*

Comments

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