Sign Up Your Store Today
Fill out this form and someone from our team will be in touch with you shortly to complete setup.
Owner Name:
*
First Name
Last Name
Owner's Email (please do NOT put store's email here)
*
example@example.com
Owner Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Name + Address
Do you already have a Box Labs owner's account?
*
Yes
No
Pharmacy Trade Name
*
Pharmacy Corporation Name
Email For Invoicing
*
example@example.com
Pharmacy Email
*
example@example.com
Pharmacy Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dispensing Software
*
Please Select
Kroll (Telus)
Fillware
What POS system are you currently using? (If you do not have one simply enter N/A)
*
Do you plan on RENTING or PURCHASING the hardware?
Please Select
Rent
Purchase
Box Labs is compatible with the INGENICO DESK 5000 from Moneris, Chase, TD, Global Payments. Please ensure you have this model PRIOR to installation. We are also compatible with Clover devices
What is your current debit / credit machine provider?
*
Please Select
Global Payment
Moneris
TD Bank
Chase
Clover
Other
What wholesalers do you currently use? (you can select more than one)
*
Kohl & Frisch
McKesson
LPG
What is your ideal install date?
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
Please Select
Word of Mouth
OPA
OnPharm
Other ...
Enter Deal Code (if applicable):
Please verify that you have all the Windows credentials to allow us to install software. For example, many machines running Kroll will prompt you for a storeadmin or admin password via the Windows prompt when you try to install any program. If you do not have this password, please call Fillware/Kroll for it - we cannot install Box otherwise. *
*
I have read and understood this
Submit
Should be Empty: