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    Section 1 of 4

    PROVIDER PORTAL INFORMATION & LOGIN

    Please note: This email will be used to recover your password for the dosing calculator in the event it is lost or you have for forgotten.

    Email address


    Provider Portal Login

    Please select your desired username and password below.

    Username (case sensitive)


    Password (case sensitive)



    Section 2 of 4

    PRACTICE INFORMATION

    This information will be used on any customized marketing materials including the brochures.

    Practice Name


    Specialty


    Primary Contact Name


    Business Hours


    Phone


    Primary E-mail


    Fax


    Website


    Address


    City


    State


    Zip



    Section 3 of 4

    PHYSICIAN'S INFORMATION

    Full Name (with credentials)


    Phone


    Home Address


    City


    State


    Zip


    Active Medical License #


    Is your Medical License in good standing?

    yesno

    Malpractice Insurance


    Malpractice Policy #


    DEA License #


    Is your DEA License in good standing?

    yesno

    Do you need to add more Prescribers

    noyes


    [group group-4]

    Section 4 of 4

    ADDITIONAL PRESCRIBERS

    Please add any additional prescribers below.

    Full Name (with credentials)


    Title


    DEA License #


    Do you need to add more Prescribers

    noyes
    [/group]
    [group group-5]

    Full Name (with credentials)


    Title


    DEA License #


    Do you need to add more Prescribers

    noyes
    [/group]
    [group group-6]

    Full Name (with credentials)


    Title


    DEA License #



    [/group]