NEW ACCOUNT SET-UP

REVOLUTION RX COMPOUNDING PHARMACY

New Account Set-Up Form
REVOLUTION RX COMPOUNDING Pharmacy

7700 Main St.

Houston, TX 77030

Monday – Friday, 9:00 am – 6:00 pm CST
Instructions on filling out the form and our contact information:

1. Complete, and submit the New Customer Set-Up Form along with Billing Information prior to the first order being processed .

Fax: 832.376.7459 E-mail: compounding@mywecarex.com

As a new customer, you will automatically be enrolled in our pharmacy system which allows the prescriber or staff to place orders via jotform, phone, fax, or email. After the requested information is processed, you will receive a welcome email within 24 hours with important information.

We look forward to building a long-term relationship with your company and thank you for your business.

Please contact us at 832.234.4126 if you have any questions.
NAME OF BUSINESS/ PRACTICE*
TODAY’S DATE*

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BUSINESS/PRACTICE ADDRESS*

STREET ADDRESS OF BUSINESS/ PRACTICE

Street Address Line 2

CITY OF BUSINESS/ PRACTICESTATE OF BUSINESS/ PRACTICE

ZIP OF BUSINESS/ PRACTICE
WEBSITE OF BUSINESS/ PRACTICE
PHONE OF BUSINESS/ PRACTICE*
FAX OF BUSINESS/ PRACTICE*
CONTACT PERSON FOR ORDER QUESTIONS*
TITLE OF CONTACT PERSON*
CELL PHONE/PHONE OF CONTACT PERSON*
EMAIL OF CONTACT PERSON*
example@example.com
ACCOUNTING CONTACT PERSON*
ACCOUNTING CONTACT EMAIL*
example@example.com
EMAIL FOR RECEIVING INVOICES*
example@example.com
BUSINESS/PRACTICE SPECIALTY*
ESTIMATED ANNUAL BUSINESS $
HOW DID YOU HEAR ABOUT US
DAYS & HOURS OF BUSINESS /PRACTICE OPERATION
Check all that apply*

Patient-Specific WellnessOffice-Use WellnessPain ManagementNuclear
SALES REP
PRESCRIBER INFORMATION
PRESCRIBER NAME*
CREDENTIALS*

MDDONDNPARNPPAOTHER
Medical License#*
DEA#*
NPI #*
CELL PHONE/PHONE OF PRESCRIBER*
EMAIL OF PRESCRIBER*
example@example.com
PRESCRIBER NAME
CREDENTIALS

MDDONDNPARNPPAOTHER
Medical License#
DEA#
NPI #
CELL PHONE/PHONE OF PRESCRIBER
EMAIL OF PRESCRIBER
example@example.com
PRESCRIBER NAME
CREDENTIALS

MDDONDNPARNPPAOTHER
Medical License#
DEA#
NPI #
CELL PHONE/PHONE OF PRESCRIBER
EMAIL OF PRESCRIBER
example@example.com
BILLING INFORMATION
We will contact you for the credit card number and expiration date. A credit card must be on-file before we fill the 1st order.
EMAIL FOR RECEIVING INVOICES*
example@example.com
PRESCRIBER & PHARMACY AGREEMENT
By submitting a prescription or order, you acknowledge that you have evaluated commercially available drug product options and determined that this compounded product is clinically necessary for the patient(s) to whom this product will be administered.

1. The person(s) signing this New Customer, Terms & Conditions form warrants that the above information is complete and accurate and hereby agrees to the following terms and conditions:

2.The undersigned agrees to immediately notify REVOLUTION RX COMPOUNDING Pharmacy of any change in ownership, form or business name of the entity.

3.This document will be as effective in photocopy or fax form as in the original.

4.The undersigned acknowledges that REVOLUTION RX COMPOUNDING Pharmacy may limit or discontinue credit at its sole discretion and that the continued extension of credit may require additional information from time to time.

5.The undersigned warrants that they have full authority to sign this agreement and obligate the entity hereunder.

6. The undersigned agrees that if all invoices are not paid when due, they will accrue late charges at the rate of 1.5% per month or the maximum rate allowed by law, whichever is less. If it is necessary to take legal action, jurisdiction shall be the State of Texas and the venue shall be Harris County, Texas. The undersigned agrees to reimburse We Care Rx Specialty and Infusion Pharmacy for any attorney fees, court costs or other costs of collection which may be incurred in its efforts to collect any past due debts.

7. Compounded items may require an attestation of clinical difference from the prescriber, practitioner administering the preparation or practitioner’s representative prior to the order being filled.
SIGNATURE*

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DATE*

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Phone Orders

832-234-4126 - Sterile Compounding, Specialty and Infusion

Fax Orders

832.376.7459 – Sterile Compounding, Specialty and Infusion
PRESCRIBER AND BILLING INFORMATION
Should be Empty:

REVOLUTION RX COMPOUNDING PHARMACY

PRESCRIBER INFORMATION

BILLING INFORMATION

PRESCRIBER & PHARMACY AGREEMENT

PRESCRIBER AND BILLING INFORMATION