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HOME
OUR PHARMACY
PCAB ACCREDITED
PCCA STANDARD™ ADVANTAGES
COMPOUNDING FAQS
METHODS OF DELIVERY OFFERED
WHAT’S NEW
SUPPLEMENTS
CONTACT
CONTACT INFORMATION
EMPLOYMENT OPPORTUNITIES
NOTICE OF PRIVACY PRACTICES
NEW ACCOUNT
Search for:
HOME
OUR PHARMACY
PCAB ACCREDITED
PCCA STANDARD™ ADVANTAGES
COMPOUNDING FAQS
METHODS OF DELIVERY OFFERED
WHAT’S NEW
SUPPLEMENTS
CONTACT
CONTACT INFORMATION
EMPLOYMENT OPPORTUNITIES
NOTICE OF PRIVACY PRACTICES
NEW ACCOUNT
Certification
Certification
cre8Padmin
2023-03-02T14:28:30-05:00
Client Information Form SSRP CERTIFICATION
"
*
" indicates required fields
Step
1
of
3
33%
How did you find us?
Website
Conference (please specify Conference)
Referral
Phone call (Please specify CRE8 representative)
Conference attended
CRE8 Representative
CLINIC INFO
Clinic Name
*
Phone
*
Fax
Clinic Address
*
Street Address
City
State
ZIP / Postal Code
Email
*
Enter Email
Confirm Email
DOCTOR(S) INFO
ALONG WITH THIS APPLICATION PLEASE UPLOAD A COPY OF YOUR MOST CURRENT: DEA LICENSE & STATE LICENSE
Doctor Name (1)
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Suffix
DEA License Number
*
State License Number
*
NPI License Number
*
Upload copy of State and DEA License here.
*
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Doctor Name (2)
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Suffix
DEA License Number
State License Number
NPI License Number
Upload copy of State and DEA License here (Doctor 2)
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
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.
Electronic Consent
I agree that all prescriptions sent to CRE8 Pharmacy have met the criteria above. I agree that there is no other agreement, oral, or otherwise that negates this one.
Please enter your initials to bind the understanding of this agreement.
Your signature will be required after submission of this document.
CLINIC AUTHORIZED PERSONNEL
Name
First
Last
Title
Phone
Name
First
Last
Title
Phone
CREDIT CARD - A/R Request Form
Billing Address
Same as above
Street Address
City
State
ZIP / Postal Code
Contact Personnel to Receive Emailed Statements
Name (1)
*
First
Last
Email (1)
*
Phone (Ext/Cell) (1)
*
Name (2)
First
Last
Email (2)
Phone (Ext/Cell) (2)
Consent
Credit Card Authorization
I (we) hereby authorize CRE8 Pharmacy to make recurring charges to my Credit Card listed below, and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until CRE8 Pharmacy is notified by me (us) in writing to cancel it in such time as to afford CRE8 Pharmacy and/or Credit Card Company a reasonable opportunity to act on it. All receipts are sent directly to the cardholder within 24 hours. All records are kept in a secure file electronically password protected and accessible to authorized personnel only.
Please enter your initials to bind the understanding of this agreement.
Your signature will be required after submission of this document.
Credit Card Info
*THIS FORM MUST BE COMPLETED IN FULL FOR COMPLIANCE AND PROPER PROCESSING OF ACCOUNT*
Name on Card
*
First
Middle
Last
Billing Zip Code
*
Type
*
Visa
MasterCard
American Express
Credit Card Number
*
Exp Date
*
CVV#
*
CLINIC A/R ACCOUNT
CC POS DAILY
- CC CHARGED ON DAY ORDER IS SHIPPED. NO DETAILED INVOICE INCLUDED.
A/R DAILY
- CC CHARGED ON DAY ORDER IS SHIPPED. DETAILED STATEMENT WILL BE EMAILED THE FOLLOWING WEEK.
A/R WEEKLY
- CC CHARGED EVERY MONDAY FOR ALL ORDERS PLACED THE PREVIOUS WEEK. DETAILED STATEMENT WILL BE EMAILED EVERY MONDAY
Return, Refund & Compounded Medication Policy
Return & Refund Process
CRE8 Pharmacy cares about your complete satisfaction with our compounds and products. You may return any item purchased from CRE8 Pharmacy, as long as it meets the following conditions:
You have contacted us/returned the item to us within 72 hours of receipt. This is strictly enforced.
No item that has been opened or used can be returned except when the item has been damaged during shipment or is defective.
Inquires regarding a missing package/item must be made to the pharmacy within 48 hours of the package being shipped from our facility.
When you receive your order, please review to ensure it is in good condition (i.e. not damaged or defective) and let us know right away if there is a concern with your shipment. CRE8 Pharmacy will credit or exchange unused, defective items in their original packaging if they are returned within 72 hours. If you believe your return request should be assessed beyond our listed return policy (i.e. for damages, defects, etc.), please contact customer care for further assistance.
We strive to provide top quality customer care to you, therefore, please contact us immediately if there is an issue with your order. Please contact us at 888-224-5181 with information about your purchase, including your prescription number and list of the affected products. We will have a Customer Service Associate respond to you as quickly as possible. Please do not discard any items unless you have been directed to do so by a Customer Service Associate.
Return Shipping & Processing
Please return your medication in the original box your order arrived in. This should be sufficient to ensure that your return arrives at our pharmacy undamaged. Padded envelopes may not be an effective way to protect your return shipment, as items may be crushed during transit. Please pack your return shipment securely to ensure that the items are not damaged in transit. We will provide free return shipping if your return is the result of our error (damaged, defective, or incorrect item, etc.). Once we receive your return, we will issue a credit or refund within 7 days and send you an email confirmation. Please note that it can take several days for the transaction to appear on your account, depending on your financial institution.
Compounded Medication Disclaimer
By Definition: Drug compounding is often regarded as the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient. Compounding includes the combining of two or more drugs. Please keep in mind that not all medication works the same for each patient. CRE8 Pharmacy is not responsible for patients who claim that something is not working for them personally. CRE8 Pharmacy will gather information from both the patient and the prescriber to come to a solution that fits all parties.
Thank you for your cooperation, CRE8 Pharmacy Team
Consent
*
I agree and understand the terms outlined above.
Please enter your initials to bind the understanding of this agreement.
Your signature will be required after submission of this document.
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