Onboarding Questionnaire

Initial intake form that is sent to the clinic to gather all information needed to create their Pharmetika account

Practice Name *

Address

Street Address *

City *

State *

Country *

Postal Code *

Main Phone *

Main Email *

Clinic Website

Provider Name

Provider Phone

NPI # *

DEA #

Office Manager Name

Office Manager Phone

Office Email

Office Fax Number

Provider Name 2

Provider Phone

NPI #

DEA #

Office Manager Name

Office Manager Phone

Office Email

Office Fax Number

Provider Name 3

Provider Phone

NPI #

DEA #

Office Manager Name

Office Manager Phone

Office Email

Office Fax Number

What medications are you willing to prescribe? *

Existing Invoices

If you’d like to provide invoices from your orders, our team can review and provide our pricing

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF Max. file size: 300 MB.

Who will pay for the medications? *

Company

Patient

Either Company or Patient

Is the patient signature required for controlled substances?

Yes

No

Will you use PMP & perform background checks for controlled substances?

Yes

No

Where will the medication be shipped to?

Company

Patient

Delivery Method

Overnight

Standard

Note: Millers Pharmacy may need to contact your patients if we have questions related to their Medical Profile.