Provider Services

Provider Registration and Request Form

Everything you need to prescribe, coordinate, and support your patients—without friction. Complete this form to request prescription forms, ask about a compound, or to set up your prescriber profile in our systems to start prescribing. If you are registering more than one Doctor/Provider in your practice, you must submit this form for each individual. Please note: We do not make: peptides, IV nutrients or vitamins, growth hormones, tirzepatide, semaglutide, or other weight loss compounds.
Get prescription form(s)Ask about a compoundBecome a New Provider to start prescribing
Provider Information

We will use your NPI to verify your credentials.
Doctor/Provider Name*

First NameLast Name
Credentials*
Direct Phone Number*
Please enter a valid phone number for the Pharmacy to directly reach the Provider.Format: (000) 000-0000.
Provider/Doctor Email Address
This should not be your office email. example@example.com
Doctor/Provider NPI#*
NPI# provided must be valid (10-digits)
DEA# (if applicable)
Required if you plan to prescribe controlled substances
State(s) Licensed In
Practice Information
Practice/Business Name*
Office Admin / Point-of-Contact Name*

First NameLast Name
Office Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Office Fax Number*
Please enter a valid fax number.Format: (000) 000-0000.
Practice General Email Address*
example@example.com
Practice Website*
Enter URL (can leave out https://)
Number of Prescribing Providers at Practice*
Enter a number.
Estimated Number of Compound Prescriptions Prescribed per Week*
Enter an approximate number that best reflects across all Providers and Patients.
Practice/Business Address (Main)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Script Form Request
AtropineBHRTColorectalDermatologyENTFamily PracticeFertilityGastrointestinalMagic Mouthwash / DentistryOBGYNPain SpecialistsPediatricPhysical TherapyPodiatryUrologyVeterinaryOther
Anticipated First Prescription Date

MonthDayYear
Date
Compound Inquiry
Describe Compound / Formulation, Strength, Dosage Form*
Describe formulation requirements or patient considerations. Do not include any patient-identifying information (PHI).
Therapeutic Area / Intended Use*
YesNo
Your Experience & Preferences
How did you hear about Valor?*
Which compounding pharmacies have you worked with? (Optional)
Patient ExperienceProduct ConsistencySpeed / Turnaround TimeFormulation BreadthClinical SupportPricingOther
Anything else you'd like us to know?
Referring Provider Name

First NameLast Name
Conference Name
Valor Rep Name
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Form Source Name for HubSpot
- Authorization to Receive Faxed and/or Email Communications from Valor Compounding Pharmacy
  
  To improve the efficiency of communication with your office, Valor Compounding Pharmacy may send important updates, formulary information, clinical resources, prescription forms, and operational notices by fax and/or email.
  
  Federal and/or state regulations require that we obtain your permission to send faxed or emailed communications that may include educational or promotional information about our services. You have the right to decline these communications, and your decision will not affect our ability to serve your patients.
  
  Operational communications that do NOT require this authorization
  
  Regardless of your selections below, Valor Compounding Pharmacy will continue to contact your practice by fax, email, or phone as needed to:
  - Confirm, clarify, or follow up on prescriptions your providers have written
  - Coordinate patient-specific orders, refills, and continuity-of-care matters
  - Notify your practice of compounding delays, shortages, or formulation changes affecting active prescriptions
  - Respond to inquiries your office initiates
  These communications are part of the pharmacist-prescriber relationship and do not require separate authorization.
  
  How to revoke or change your preferences at any time
  
  You may revoke this authorization, change your preferences, or opt out of any specific communication channel at any time by:
  - Calling the pharmacy's main line at 510-548-8777
  - Emailing our Communications team at marketing@vcprx.com.
  Opt-out does not remove your practice from our records and does not affect operational communications described above.
- YES, our office authorizes Valor Compounding Pharmacy to send emailed educational and promotional communications to the email address(es) provided.NO, our office does not wish to receive email educational and promotional communications. (Operational emails described above will be sent as needed.)
- YES, our office authorizes Valor Compounding Pharmacy to send faxed educational and promotional communications to the fax number provided.NO, our office does not wish to receive faxed educational or promotional communications. (Operational faxes described above will still be sent as needed.)
- I confirm the information above is accurate and I am the licensed provider named, or I am authorized to submit on behalf of the provider named.I understand that declining educational or promotional communications does not affect Valor Compounding Pharmacy's ability to contact our practice regarding active prescriptions, patient-specific orders, or continuity-of-care matters.I understand this form is for provider business inquiries and should not contain patient protected health information (PHI).I have read and agree to Valor's Terms of Service and Privacy Policy (links found in the footer of our website.)
- Electronic Signature*
- Valor Compounding Pharmacy is a 503A compounding pharmacy. For a current list of licensed states, please visit our States We Serve page. Registration with Valor is subject to verification of professional licensure in applicable jurisdictions. This form is a business inquiry and does not constitute a prescription, patient-specific order, or commitment by either party. Do not include protected health information (PHI) on this form. For secure patient-related communications, please call the pharmacy at 855-554-2889 to speak directly with a pharmacist.
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Provider Registration and Request Form

Provider Information

Practice Information

Script Form Request

Compound Inquiry

Your Experience & Preferences