Pegasus Complete Enrollment Form

Enrollment Form

Please fill out the form below, and a representative will get back to you shortly.
Facility Name*
Physician Name(s)*
Please list all physicians.
Phone #*

Area CodePhone Number
EIN/TAX ID #*
DEA #
Required for Pharmacy Access
Speciality
e.g., cardiology, pediatrics
Contact's Name*

PrefixFirst NameLast Name
Contact's Position
E-mail*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please list any other locations (names and addresses).
Current Distributor(s)
Distributor Account Numbers
Distributor Rep's Name
Pegasus Complete Membership Agreement

Please review the entire agreement and then check the box below.
Your Signature

Clear
Today's Date

MonthDayYear
Date
Any additional questions or comments?
Should be Empty:

Enrollment Form