HRX New Clinic Inquiry Form

Join HRX Pharmacy Today!

Sign up your medical clinic to become a provider with HRX Pharmacy and start filling your patients' prescriptions conveniently through mail or at one of our nearby locations. Once accepted by our team, you’ll receive access to our user-friendly portal for submitting prescriptions.

Getting Started is Easy—Just Follow These 3 Steps:
1. Complete the New Clinic Inquiry Form below.
2. Check your email! After submission, we'll send you a follow-up form to gather information about the providers in your clinic who will be prescribing.
3. If you selected the "Bill Office" option, we'll also include a link to the "Clinic Billing Form" in that email.
Clinic Name*
Clinic Website Address
Patients per Month*
Clinic Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a National or Regional Telehealth-Only Company?
Clinic Specialties

CardiologyDentalGeriatricsMed SpaNeurologyOpthamologyPediatricsPrimary CareSports Medicine ClinicVeterinary ClinicWomen's HealthChiropracticDermatologistHormone ClinicMen's HealthOncologyPlastic SurgeryRheumatologyUrologyWeight Loss ClinicOther
Contact Information
Clinic Contact First Name*
First Name
Clinic Contact Last Name*
Last Name
Role at Clinic*
(Ex: Office Manager, Lab Technician)
Email*
example@example.com
Phone Number*
"By providing your mobile number, you consent to receive SMS messages from HRX Pharmacy regarding updates, promotions, and important notifications. Message and data rates may apply. Reply STOP to opt out at any time. Your information will remain confidential and will not be shared with third parties without your consent."
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Join HRX Pharmacy Today!

Getting Started is Easy—Just Follow These 3 Steps: