Client Information Form

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CLINIC INFO

Clinic Address*
Email*

DOCTOR(S) INFO

ALONG WITH THIS APPLICATION PLEASE UPLOAD A COPY OF YOUR MOST CURRENT: DEA LICENSE & STATE LICENSE
Doctor Name (1)*
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    Doctor Name (2)
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      To ensure that all prescriptions received by CRE8 Pharmacy are pursuant to a valid patient/doctor relationship, we require that our prescribing physicians agree that the following elements are satisfied prior to sending us a prescription. For the purposes of state law, many state authorities, with the endorsement of medical societies consider the existence of the following elements as an indication that a legitimate doctor/patient relationship has been established:


        1. A physical examination has been performed
        2. A medical history has been taken
        3. A patient has a medical complaint
        4. Some logical connection exists between the medical complaint, the medical history, the physical examination and the drug prescribed.
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