Medical Director Authorization
Please Print or Type:
Facility Name:________________________________________________________________ Account #__________________________
Contact Name:__________________________________________ E-mail address:___________________________________________
Company Shipping Address: ______________________________________________________________________________________
City: ___________________________________ State: _____________ Zip: ______________ Telephone: ________________________
Does customer have multiple shipping addresses?
*If there is more than one shipping address, please
include an attachment with additional addresses.
PHYSICIAN LICENSE INFORMATION
I, the undersigned, am the Medical Director for the above-named facility at the above-specified shipping address. In this capacity, I hereby authorize the facility to authorize the below-indicated category(ies) of products and submit the following referenced license(s) with respect to such orders, with a copy of such license(s) attached to this form.
I wish to order Prescription Drugs and/or Medical Devices. License authorizing these items is as follows:
Physician’s License or State Board of Pharmacy License #_______________________ Expiration Date: ____________________
I hereby swear under penalty of perjury that (i) I am the (check one): Medical Director Pharmacist-in-Charge with responsibility for the facility identified above in Part A with respect to the specified address; (ii) that the license information provided is current and accurate and I am, therefore, licensed to authorize shipment of the substances indicated on this form to the facility designated.
Signature: _____________________________________________ Date: _________________
Print Name: ____________________________________________ Print Title: _______________________________________________
Phone: ____________________________ Email: ____________________________________
This Authorization is only valid if accompanied by a copy of the license specified above. This Authorization will expire at the time of the expiration of the above-specified license (as applicable to the product ordered). Upon expiration, a new Authorization must be submitted for orders to be processed. If there is a change in Medical Director, this Authorization will immediately become invalid and a new Authorization, including applicable license(s), must be submitted for orders to be processed.