Puramint Application Form

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?

No, this is a new account.No, but referred by HaldeyYes, PuramintYes, HaldeyYes, Both
Is your clinic currently open for Business?

YesNo
Practice Name*
Practice Contact Name
Practice Contact Email
Practice Phone Number*
Please enter a valid phone number.
Practice Fax Number*
Please enter a valid phone number.
Website URL*
Instagram Handle
Facebook Handle
Office Contact
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.
Need Level:*

One time or one patient>5 patientsEssential to Business operations
What types of medications are you interested in?*
How are patients seen?

In PersonTele-HealthPrimary In-Person and some Tele-Health
For the compounded preparation(s) of interest, how many total prescriptions do you expect to order per month?*

<22-1011-2525-5050+
When do you expect to prescribe with Puramint for the first time?*

This weekWithin 2 weeksWIthin 1 monthUndecidedNeed Pricing
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the shipping address:

ResidentialCommericial
Standard Billing Option

Bill to PatientBill to ClinicMixed
Standard Shipping Option

Ship to PatientShip to ClinicMixed

Type a question

	Information
Name
Cell Phone
Fax
Email
Prescriber NPI
Prescriber DEA

Prescriber Information

Prescriber 1 Setup

	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

	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

	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

	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

	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

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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.
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.
Number of locations under same Ownership umbrella
Should be Empty:

Puramint Application Form

Office Contact

Prescriber Information