Register | American Wellness Pharmacy

Clinic Account

Clinic Name(Required)

Clinic Main Email(Required)

Clinic Phone Number(Required)

Clinic Website

Clinic Fax Number

Clinic Specialty(Required)

Family Practice

Wellness / Hormone Optimization

Aesthetics / MedSpa

Other

Clinic Address(Required)

Days and Hours of Operation(Required)

Ordering & Communications

Primary Order Contact(Required)

Primary Order Email(Required)

Email for receiving news on our latest products, price updates, and special offers.

How did you hear about American Wellness Pharmacy?(Required)

Authorized Agents (CSA)

Authorized Agents

List of individuals given permission and responsibility to order, change, and cancel any prescriptions created by the clinic. The CSA defines an “agent” as “an authorized person who acts on behalf of or at the direction of a manufacturer, distributor, or dispenser." 21 U.S.C. 802(3). Under the CSA, the term “dispense” includes “prescribing.” 21 U.S.C. 802(10).

Prescriber 1

Prescriber's Name

First Last

Prescriber's Email

Credentials

NPI#

DEA#

Add Another Prescriber

Yes

Prescriber 2

Prescriber's Name

First Last

Prescriber's Email

Credentials

NPI#

DEA#

Add Another Prescriber

Yes

Prescriber 3

Prescriber's Name

First Last

Prescriber's Email

Credentials

NPI#

DEA#

Upload Licenses(Required)

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, heic, Max. file size: 5 MB, Max. files: 8.

Cardholder Name(Required)

First Last

Cardholder Email(Required)

Cardholder Phone(Required)

Credit Card Number(Required)

Exp(Required)

CVV(Required)

Billing Address(Required)

Same as Clinic Address

Billing Authorized Agents

American Wellness Pharmacy securely stores your payment method for clinic-billed medications. Charges are processed before delivery of clinic-billed items. Accounts with declined payments may be placed on hold and may be subject to late fees or collections. By signing and saving a payment method, you authorize American Wellness Pharmacy to use this payment method for clinic-billed medications until you revoke authorization in writing.

Billing Authorization Signature(Required)

Applicants Name(Required)

Persons representing clinic and responsible for submitting AWP account application

American Wellness Pharmacy respects your privacy and will NEVER share your information with any unauthorized parties. We use your information only to manage your account and deliver the products and services you’ve requested, along with receiving news on our latest products, price updates, and special offers which you can unsubscribe from at any time. Please check the box below acknowledging your consent:

To learn about our privacy practices and commitment to protecting your information, please review our Privacy Policy on our website.

Signature(Required)

Provider Application

Clinic Account

Ordering & Communications

Authorized Agents (CSA)

Prescriber 1

Prescriber 2

Prescriber 3