Client Application
Please provide the following information or you may complete and return the PDF version of this form.
To ensure the quickest turnaround time, be sure to include an electronic copy of the
ordering Healthcare Practitioner's license that shows the expiration date or
a copy of a voided prescription pad form showing license number.
Thanks for submitting your information to us online. A Client Services representative
will contact you shortly with your account details.
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Uploaded license file size is larger than the max upload size of 12.5 MB. Please resize the file or choose a new license file to upload.
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