Sweetgrass Pharmacy Application Form
Please note: Part of the application process is a website and social media review. Any comparison of compounded products to FDA approved products can be a cause for immediate denial. Sweetgrass Pharmacy and Compounding operates in compliance with the legal requirements of section 503A of the FD&C Act. All prescriptions must be patient-specific, and prescribers are responsible for fulfilling their legal obligations when issuing prescriptions.
Do you currently have an account with Sweetgrass Pharmacy?
Yes
No
Is your practice currently open for business?
Yes
No
Practice Details:
Practice Name
*
Practice Phone Number
*
Practice Fax Number (if applicable)
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Instagram Handle
Facebook Handle
Office Contact
Who should we contact for non-clinical questions?
*
First Name
Last Name
Cell Phone Number
E-mail
example@example.com
Level of Need
*
One time or for one patient
5 or more patients
Services essential to business operations
What types of medications are you interested in?
*
How are your patients seen?
In Person
Telehealth
Primary In-person and some Telehealth
For the compounded preparation(s) of interest, how many total prescriptions do you expect to order per month?
*
<2
2-10
11-25
25-50
50+
When do you expect to prescribe with Sweetgrass Pharmacy for the first time?
*
This week
Within 2 weeks
Within 1 month
Undecided
Need Pricing
Prescriber Information
Prescriber 1 Setup
*
Rows
Contact Number
Name
Cell Phone
NPI Number
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)
Prescriber 1 Email
example@example.com
Do you have more than one provider associated with your practice?
*
Yes
No
Prescriber 2 Setup
Rows
Information
Name
Cell Phone
NPI Number
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)
Prescriber 2 Email
example@example.com
Prescriber 3 Setup
Rows
Information
Name
Cell Phone
NPI Number
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)
Prescriber 3 Email
example@example.com
Prescriber 4 Setup
Rows
Information
Name
Cell Phone
NPI Number
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)
Prescriber 4 Email
example@example.com
Prescriber 5 Setup
Rows
Information
Name
Cell Phone
NPI Number
License Type (MD, DO, PA, APRN/NP, Other)
Role at Clinic (Staff, Owner, Part-time)
Prescriber 5 Email
example@example.com
Medical Director
*
First Name
Last Name
Medical Director Email
*
example@example.com
Medical Director Phone Number
*
Please enter a valid phone number.
Owner:
*
First Name
Last Name
Owner Email
*
example@example.com
Owner Cell Phone Number
*
Please enter a valid phone number.
Number of locations under the same ownership umbrella
Are you wanting medications billed to your office or to your patients?
*
Office
Patients
Mixture- based on drug and patient
Best email for us to send Credit Card Authorization form to. *** A 3% Fee will be applied to all payments using a credit card. To avoid this fee please submit a debit card and specify which kind of card you are submitting***
*
example@example.com
How did you hear about us?
*
Please Select
Internet
Referral
Reached out to by sales representative
What sales representative?
*
Please Select
Caroline Hennecy
Susan Dunn Britton
Colleen Troy
Sydney Vance
Not sure
Please Specify
Submit
Should be Empty: