DaylightRx Onboarding
Thank you for your interest in DaylightRx! Please fill out the following form to get started.
Pharmacy Corp/Legal Name
*
DBA (Doing Business As)
If applicable
Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What pharmacy management system do you currently use?
*
PioneerRx
Liberty
PrimeRx
BestRx
QS1
Rx30
SRS
DRX
Opus
Data Scan
Digital Business Solutions
Foundation
Other
If you selected "Other," please specify below.
NCPDP/NABP
*
NPI
*
BOP License
*
Browse Files
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Choose a file
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of
DEA License
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Pharmacist-in-Charge Name
*
First Name
Last Name
Pharmacist-in-Charge Contact Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacist-in-Charge Contact Email
*
example@example.com
Best method to contact
*
Phone
Email
DaylightRx User Access
*
Rows
Full Name
Login Email
Title
User 1
User 2
User 3
Please enter the email address where you'd like to receive invoices:
*
example@example.com
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Direct Manufacturer Relationships
Please select all manufacturers you purchase from directly.
*
Dermavant/Organon
Mayne
FFF
Incyte
Journey
JG
Other
If "Other", please specify the manufacturer(s) here.
Do you purchase direct from Arcutis?
*
Yes
No
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Signer Name
*
First Name
Last Name
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
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DaylightRx Walkthrough
After signing this document, you'll be redirected to schedule a walkthrough of DaylightRx. Click "Next" to continue.
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Signature
*
Must be authorized signer
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Should be Empty: