REGENERATIVE PRACTICES OF AMERICA NEW ACCOUNTS ONLY

Our highly experienced staff will be taking care of you shortly and we all look forward to being a part of your success. At CRE8 Pharmacy we are dedicated to providing the medical community with the highest quality of pharmacy services. In order for us to service your clinic, please complete the following forms at your earliest convenience.

Client Information Form Regenerative Practices of America

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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.
      Your signature will be required after submission of this document.

      CLINIC AUTHORIZED PERSONNEL

      Name
      Name