• Complete & Upload Required Documents

  • *All fields required unless noted.

    • 1. DEA Registration Information 
    • Are you changing the veterinarian of record for your hospital?*
    • Customer type: (select all that apply)*
    • DEA Registration Schedules: (Check all that apply)*
    • DEA Registration Expiration Date:*
       - -

    • DEA Registration Address

    • Registered State Licenses & Registrations:
      (DVM, DEA, HCCE, etc.) *

      Upload all relevant state-level licenses, including DVM, DEA Registration, and/or clinic licenses (e.g., HCCE). Each license must be valid and match the business address.

    • 2. Business Information  
    • Business Type*
    • Does your business have a DBA?*
    • Is the DEA Registration address the same as the business address?*
    • Format: (000) 000-0000.
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    • 3. Controlled Substance Protocol 
    • Has any registrant at this location been inspected by any licensing authority, including DEA, in the past 5 years?*
    • Is any registrant or any practitioner/employee currently under investigation by any licensing authority, including DEA?*
    • Has registrant or any practitioner/employee had a license or registration denied, revoked, or suspended by any licensing authority, including DEA?*
    • Does the storage location meet the security requirements of 21 CFR §1301.75(b)?*
    • Is access to the controlled substances limited?*
    • Is any employee authorized to sign on behalf of the hospital DEA Registrant?*
    • Does employee authorized to sign DEA forms 222 have a valid Power of Attorney (POA) on file at the registered location?*
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    • How often are controlled substances ordered?*
    • Do you sell or transfer controlled substances to any other registrant?*
    • Does the facility have a contract with a Reverse Distributor?*
    • 4. Signatures 
    • 5. Upload Photos 

    • Please note:

      • If you are only changing the veterinarian of record, you do not need to submit new facility photos.

      • If you have moved to a new facility or your security measures have changed, you must submit new photos.

      • Photos below must be submitted before your due-diligence form is approved unless you have previously submitted them.

    • Photo Documentation Quick Guide

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    • The Code of Federal Regulations, 21CFR Part 1301.74(b) requires distributors of controlled substances to design and operate a system to identify suspicious orders. Suspicious orders may include those of unusual size, deviating substantially from a normal historical pattern, and/or orders of unusual frequency.

    • Out of accordion elements: 
    • Should be Empty: