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Client Intake Form

Name of Clinic:

Address:

City:

State:

Zip:

Phone Number:

Fax:

Website:

Prescriber information (as it appears on script)

Prescriber’s name & title:

DEA#

NPI #

Prescriber’s name & title:

DEA#

NPI #

Prescriber’s name & title:

DEA#

NPI #

Where would you like your prescriptions sent?

Patient directly Doctor’s office

Billing Contact Information

Accounts Payable:

Email Address:

Phone Number:

Billing Payment Information

Name on Card:

Card Billing Address:

Card Type:

Card Number:

Expiration Date:

Security Code: