CPESN Scripted Signup Form

Ready to get started with Scripted?
Share some info with us and we'll review what we can do for your pharmacy.

Additional questions? Email bizdev@scripthealth.co or book some time to chat.
Pharmacy Information
Pharmacy Legal Name*
e.g., LD Pharmacy LLC
Pharmacy Name (DBA)*
e.g., Legal Drugs Pharmacy
Pharmacy NPI*
Pharmacy Address
Street 1*
Street 2
City*
State*
Two letter State - e.g., CA = California
Zipcode*
Person Signing
First Name*
Last Name*
Email*
Mobile Phone*
Select your product
Scripted Direct Pay PlatformScripted Direct Pay Platform + Unlimited Agreements (CPAs)
Should be Empty:

Ready to get started with Scripted?