Welcome to Logic Med Partners! Please complete this form to register your practice with our pharmacy. All information is confidential and used solely for onboarding and account setup.

Email *

Physician Information

Full Name

Address

Street Address

City

State

Country

Postal Code

Phone *

Practice Name

Preferref Method of Contact

Phone

Professional Details

NPI Number *

License Number(Optional)

DEA Number (if applicable)

Specialty

State of Licensure *

Payment Information

Credit Card Authorization Form. Please provide payment details to authorize billing for pharmacy-related services. For security, Logic Med Partners may send a separate secure link to complete payment authorization. You will not be charged until you place an order. This information is collected only to have on file for when you want to order, and you may request that your card information be removed from our records at any time.

CardHolder Name *

Billing Address *

Credit Card Number *

Expiration Date (MM/YY) *

CVV *

Authorization Statement: I hereby authorize Logic Med Partners to charge the above credit card for pharmacy-related fees and services associated with my account. This authorization will remain in effect until I notify Logic Med Partners in writing to cancel it.

Signature

Date

Agreement and Acknowledgment

By signing below, I confirm that the information provided is accurate and that I agree to Logic Med Partners onboarding and account management policies.

Signatures *

Signed Date