Intake Form

Sales People List

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

PRACTICE / COMPANY

Practice Name *

Address

Street Address *

City *

State *

Country *

Country

Postal Code *

Main Phone *

Main Email *

Clinic Website

PROVIDER 1

Provider Name

Provider Phone

NPI # *

DEA #

Office Manager Name

Office Manager Phone

Office Email

Office Fax Number

PROVIDER 2

Provider Name 2

Provider Phone

NPI #

DEA #

Office Manager Name

Office Manager Phone

Office Email

Office Fax Number

QUESTIONS

Are the medications ordered going to be paid by *

Company

Patient

We are shipping the order to?

Provider

Patient

Is MILLERS permitted to contact Patient?

Only Provider

MILLERS may contact

Is the patient signature required for controlled substances? (Charges applies)

Yes

No

Did you approve the pricing sheet provided?

Yes

No

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

Yes

No

You agree that you have represented to MILLERS that it can rely on such information?

Yes

No

PAYMENT INFORMATION

Cardholder Name *

Billing Address *

Type *

American Express

Master Card

VISA

Other

Card Number *

Expiration Date *

CSV *

AGREED PRICING/NOTES

Agreement Notes *

Provider

Phone *

Email *

Signature: *

Date:

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