Intake Form

Sales People List *

Select an option

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 bill the clinic as an accommodation. If payment is not made by the clinic, it will be billed to the 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 *

Card 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.