US Specialty Formulations New Customer Setup Form

New Customer Set-up Form

If you are a human and are seeing this field, please leave it blank.

Fields marked with * are required

Business Name *

Please check all that apply.

Hospital

Pharmacy

Private Practice

Lab

Doctor's Name *

Medical License Number *

Person authorized to make purchases. *

Purchasing Email address *

Purchasing Phone *

Address *

City *

State *

Zip Code *

Please enter shipping location if different from above.

Shipping Address 1

Is this location approved for scheduled substances?

Shipping Location 2

Shipping Address

City

State

Zip Code

Name of Drug *

Syringe

Vial

Number per month

reCAPTCHA *