New Account Form

New Account Form
Thank you for reaching out about your interest in Designer Drugs Pharmacy
Please fill out our New Clinic Questionnaire to inquire about any of our medications, and one of our Sales and Clinic Liasons will reach out to you. If you're interested in having your clinic billed for any orders, please also fill out our Clinic Billing Questionnaire.

If you have any questions, please reach out to Sales@compound-rx.com.
How did you hear about us?*

Word of mouthEmailAdvertisementSocial MediaReferralOther
Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Office Contact Name*

First NameLast Name
Direct Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please list the following for all prescribers who will be on this account:*
Bill*

ClinicPatient
If billing clinic

CC per orderInvoice weekly
Email for Invoice*
example@example.com
Pick-up or Shipping*

Patient will pick upClinic will pick upShip to patientShip to clinic
Should be Empty:

Thank you for reaching out about your interest in Designer Drugs Pharmacy