Facility Enrollment Form

Facility Enrollment Form
Last updated: 2/12/2026

Changelog:
Thank you for choosing Hawthorne Compounding Pharmacy!

As an independent pharmacy, we value strong partnerships with prescribers and are committed to providing excellent service. We look forward to working with your practice to support your patients with reliable, high-quality compounded medications.

To get started, please complete the enrollment form below. If you have any questions or concerns about the form, please call (706) 521-0272 or email compounding@hawthornedrugs.com.
Clinic/Office Name*
Primary Contact Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number*
Please enter a valid phone number.Format: (000) 000-0000.
Billing Email*
example@example.com
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider List*
Hawthorne Drugs Courier (Athens only)Ship to facilityShip directly to patientPatient pickupOther
Pay Quickbooks invoice via ACH or PayPalCredit card on filePay by phone
I approve of monthly invoices (Net 30)Other arrangement (please specify)
Additional Notes/Preferences
If there are any ways we can make working together easier, please let us know.
Optional: Upload your Logo(s)

NOTE: your branding is only used for shared, clinic-specific materials such as prescription templates and patient PHI consent forms.
Cancelof
Signature*

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