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(Required)

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).

Thank you for registering with American Wellness Pharmacy.

Unfortunately, we’re not yet licensed to deliver to your state.
Our team is working hard to expand our coverage, and we’ll reach out as soon as your region becomes available.

If you have patients within our licensed states that we can ship to, please continue to the next page

Prescriber 1

Prescriber's Name(Required)

First Last

Prescriber's Email(Required)

Credentials(Required)

NPI#(Required)

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.

How would you like prescriptions billed?

Bill Patient Prescriptions To Clinic

Bill Patients Directly

Bill Patient Prescriptions To Clinic: This option unlocks Tier 2 & Tier 3 preferred provider pricing billed directly to your clinic. Credit card information will be required.
Bill Patients Directly: This option unlocks Tier 1 pricing billed directly to your patients for their medications. No medications or ancillaries will be billed to your clinic. No payment information is required.

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CC Fields

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

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)

Thank you for registering with American Wellness Pharmacy.

Prescriber 1

Prescriber 2

Prescriber 3

CC Fields