Business Information

Legal Business Name

Website

DBA (if applicable)

EIN / TAX ID

Business License Number

Enter Business Address

City

State

Country

Postal Code

Please Select Provider Type

Physician (MD/DO)

Nurse Practitioner (NP)

Physician Assistant (PA)

Registered Nurse (RN)

If applying as a Registered Nurse (RN), RN sections must be completed. RNs operate under Above Wellness medical oversight and are not independent wholesale purchasers. ption 3

Provider Information

Full Name

Title

Medical License #

State of Licensure

License Expiration Date

NPI

DEA (if applicable)

Email *

Phone *

By checking this box, I consent to receive non-marketing text messages from [BUSINESS NAME] about [USE_CASE_FROM_CAMPAIGN_DESCRIPTION]. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from [BUSINESS NAME] at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Supervising Physician (if applicable)

Supervising Physician Name

License Number

Physician State

Relationship (employee, contractor, etc.)

Facility & Practice Compliance

Facility Type (clinic, med spa, mobile, etc.)

Do you maintain medical records? (Yes/No)

Do you follow state-specific scope of practice laws? (Yes/No)

Malpractice Insurance Carrier

Policy Number

RN Applicants Only: Medical Oversight & Scope Acknowledgment *

I understand I will operate under the Above Wellness medical director and will not independently prescribe or source medications.

I agree to administer treatments only within my licensed scope and under approved protocols and standing orders.

I agree to follow all intake, consent, charting, and treatment requirements.

I will not source or administer medications outside of the Above Wellness platform while operating under this agreement.

Years of Experience

IV / Injection Experience (Yes/No)

Billing & Payment Setup

Billing Contact Name

Billing Email

Preferred Payment Method

Billing & Payment T&C *

I agree to pay invoices within agreed terms

I authorize a card on file if required for processing.

I understand that additional participation or platform fees may apply depending on provider type.

Shipping & Handling Acknowledgment *

I acknowledge cold shipping requirements where applicable.

I acknowledge that certain medications may have state-specific shipping limitations.

I confirm that the shipping address provided is accurate and appropriate for medical deliveries.

I understand that Above Wellness is not responsible for delays once shipments are in transit.

Permitted Use of Products & Compliance

Provider agrees that all products obtained through Above Wellness will be used solely for legitimate medical purposes within the Provider’s practice or under appropriate medical supervision. Products may be administered or prescribed to patients in accordance with applicable laws, regulations, and scope of practice.

Provider agrees not to resell, redistribute, or transfer products outside of their licensed practice or to any unauthorized third party.

All medications must be prescribed, dispensed, or administered by a licensed provider where required and in compliance with state-specific regulations.

Registered Nurses operating under Above Wellness may only administer medications pursuant to provider-approved treatment plans and standing orders.

Specific product availability and use may vary based on provider qualifications, state regulations, and clinical approval.

Compliance Statement

All medications are prescribed by licensed providers when appropriate and sourced from licensed compounding pharmacies. Approval is subject to verification and compliance review.

I accept compliance statement and permitted use of products agreement. *

I accept compliance statement and permitted use of products agreement.

License & Business Verification *

I certify that all licenses and business information provided are active, valid, and in good standing. I understand Above Wellness may verify this information at any time.

Application Acknowledgment *

I understand that submission of this application does not guarantee approval.

I understand that if approved, I will be required to review and sign the Above Wellness Provider Agreement prior to onboarding, payment, or access to products and services.

I understand that access to products, services, and ordering capabilities is subject to approval and may vary based on provider type and medical oversight structure.

Applicant Information

Full Legal Name (Typed)

Applicant Title