Qualgen - Prescriber/Pharmacy Application

Prescriber/Pharmacy Application
Applicant Information
Healthcare Provider Name
Clinic Name

N/AIf applicable, please provide the name:
Provider Type:

HospitalHealthcare systemAmbulatory surgical centerClinicPharmacyOther (provide description below)
If “other”, describe:
Supervising Physician

N/AIf applicable, please provide the name:
Contact Person

First NameLast Name
Title/Position
Pharmacist-in-Charge

N/AIf applicable, please provide the name:
Address

Street Address

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Business Information¹
Entity Type:

CorporationLLCPartnershipSole Practitioner and/or ProprietorOther (provide description below)
Describe if “Other” (if applicable)
State of Incorporation/Formation
DEA Registration Number²
Registration Number
State

Street Address

Street Address Line 2

City

Postal / Zip Code
License Number
¹ Applicant agrees to immediately notify Qualgen, LLC of any change in business ownership, name, address and registration or licensing status.

² The Controlled Substances Act provides that every person who dispenses, or who proposes to dispense, any controlled substance shall first obtain from DEA a registration issued in accordance with regulation (21 U.S.C. § 822(a)(2).

Qualgen, LLC. - INTERNAL USE ONLY
Product(s)/ Services Requested

Please list the products/services you are interested in obtaining from Qualgen, LLC:
Product/Service 1
Product/Service 2
Product/Service 3
By filing this application to acquire the above-referenced products, I attest that the applicant will only source and provide compounded medications to the extent that such medications will produce a clinical difference for an individual patient (e.g., differences in required concentration, excipients which may be allergens, etc.), when compared to the FDA-approved version of such medication, as determined by the prescribing practitioner. In other words, I affirm that the applicant will not source compounded medications that would otherwise be essentially a copy of an FDA-approved drug without exception-based circumstances such as those referenced above.

Note: This provision shall not apply if the requested medication is in shortage, as can be readily verified by FDA’s Drug Shortage list, at all times relevant to a particular transaction involving said medication.
Terms and Conditions:

1. Acceptance of Terms: By submitting this application, the healthcare provider agrees to abide by all terms and conditions set forth by Qualgen, LLC. Acceptance of this application is at the sole discretion of Qualgen, LLC.

2. Payment Terms: All payments are due within 30 days from the date of the invoice unless otherwise stated in a separate agreement. Late payments may incur interest charges at the rate of 1.5% per month. Payment may be made via credit card or wire transfer only. Cash is not accepted.

3. Pricing and Orders: Prices for products/services are subject to change without prior notice. Orders will be processed according to the availability of products/services.

4. Confidentiality: Both parties agree to maintain the confidentiality of all proprietary information received from the other party during the course of their business relationship.

5. Limitation of Liability: Qualgen, LLC shall not be liable for any indirect, incidental, or consequential damages arising out of or in connection with the provision of products/services.

6. Termination: Either party may terminate this agreement with 30 days written notice. Termination does not relieve the healthcare provider of any payment obligations for products/services already distributed or otherwise provided.

Qualgen shall immediately terminate this agreement upon the finding that any person employed by or otherwise affiliated with the applicant has been or current is under investigation by state or federal authorities for any regulatory violation(s) relating to requirements under which the applicant’s business is to be conducted.

7. Governing Law: This agreement shall be governed by and construed in accordance with the laws of the State of Oklahoma, without regard to its conflict of laws principles.

8. Entire Agreement: This application, along with any attachments or agreements referenced herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements or understandings.
Prescriber/Pharmacist Signature
Printed Name*
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Qualgen, LLC
Attention: Customer Accounts
301 Enterprise Dr. Edmond, OK 73013

P :405.551.8216 F: 405.286.3755
Should be Empty:

Prescriber/Pharmacy Application

Applicant Information

Business Information¹

DEA Registration Number²

Product(s)/ Services Requested

Terms and Conditions:

Prescriber/Pharmacist Signature