Puramint Application Form

Please Note:

Part of the application process is a website and social media review.

Any comparison of compounded products to FDA approved products can be a cause for immediate denial.

Puramint works within the legal requirements of section 503A of the FD&C.

All prescriptions must be patient specific and prescribers must fulfill their legal responsibilities for proper prescribers.

Are you currently an account of Haldey Pharmaceutical or Puramint?

Is your clinic currently open for Business?

Practice Name

Practice Contact Name

Practice Contact Email

Practice Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Practice Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Website URL

Instagram Handle

Facebook Handle

Whom should we contact for non-clinical questions?

First NameLast Name

Office Contact Email

example@example.com

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Need Level:

What types of medications are you interested in?

How are patients seen?

For the compounded preparation(s) of interest, how many total prescriptions do you expect to order per month?

When do you expect to prescribe with Puramint for the first time?

Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the shipping address:

Standard Billing Option

Standard Shipping Option

Type a question

Rows	Information
Name
Cell Phone
Fax
Email
Prescriber NPI
Prescriber DEA

Prescriber 1 Setup

Rows	Information
Name
Cell Phone
NPI
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)

Prescriber 1 Email

Must not be shared email - gmails are totally fine

Prescriber 2 Setup

Rows	Information
Name
Cell Phone
NPI
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)

Prescriber 2 Email

Must not be shared email - gmails are totally fine

Prescriber 3 Setup

Rows	Information
Name
Cell Phone
NPI
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)

Prescriber 3 Email

Must not be shared email - gmails are totally fine

Prescriber 4 Setup

Rows	Information
Name
Phone
NPI
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)

Prescriber 4 Email

Must not be shared email - gmails are totally fine

Prescriber 5 Setup

Rows	Information
Name
Phone
NPI
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)

Prescriber 5 Email

Must not be shared email - gmails are totally fine

By affixing your signature below, you, as the Medical Director of the practice, grant authorization to the above-named clinic contact to act as your agent for the purpose of providing prescription information for your patients. This authorization allows the clinic contact to relay information regarding medications you deem appropriate for dispensing.

Please note that you remain solely responsible for all prescription orders generated through this authorization. You are held liable for any future issues arising from such medications provided to your patients.

Should you wish to revoke this authorization for any reason, it is your responsibility to promptly notify the pharmacy in writing of the agent's withdrawal of authorized access.

Medical Director Signature

Medical Director

First NameLast Name

Medical Director Email

Must not be shared email - gmails are totally fine

Medical Director Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Owner:

First NameLast Name

Owner Email

Must not be shared email - gmails are totally fine

Owner Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Number of locations under same Ownership umbrella

Puramint Application Form

Office Contact

Prescriber Information