New Prescriber Application

Welcome to MedQuest Pharmacy!

Please complete the following information to get registered as a provider.

Important information: Please note that MedQuest Pharmacy bills and ships directly to patients. If you are interested in setting up a Clinic Pay account with another Belmar facility that offers this service, please click here. Thank you!

Are you completing our application as part of an event you are attending?(Required)

Which Event?(Required)

Year of Event(Required)

Month of Event(Required)

Attendee Type?(Required)

How did you hear about us?(Required)

Your Information

Prescriber Name(Required)

First

Last

Professional Designation(Required)

Email(Required)

Prescriber Cell Phone

Practice Information

Practice Name(Required)

Medical Field

Office Phone(Required)

Office fax

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Primary Office Contact

Licensing Information

NPI Number(Required)

State License Number(Required)

DEA Number

Advanced practice providers: do you have a collaborating / supervising practitioner?

Yes

Collaborating/Supervising Practitioner's Information (if applicable)

Prescriber Name(Required)

First

Last

Professional Designation(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone(Required)

DEA Number(Required)

State License Number(Required)

State CS Number (if applicable)

NPI Number(Required)

Compounded Medication Experience

Practice Tenure(Required)

Telemedicine?(Required)

Currently Practicing BHRT?(Required)

Currently Using Compounds?(Required)

Current Monthly Patient Count(Required)

Monthly Patient on Compounded Meds(Required)

Is Your Practice LegitScript Certified?(Required)

Which Medications Do You Want to Prescribe Today?

I Want to Prescribe(Required)

Hormone Pellets

Non-Sterile Medications (Capsules, Creams, Troches, Tablets, etc.)

Sterile Medications (Injectables)

GLP-1s

Monthly Patients on Hormone Pellets(Required)

Monthly Patients on Non-Sterile Medications(Required)

Monthly Patients on Sterile Medications(Required)

Monthly Patients on GLP-1s(Required)

Help us serve you better! What additional support can we offer?

Interested in learning more or scheduling an eMed Plus Training?

Yes, contact me to schedule

Considering, please send me more information

Not interested at this time

How can we help you?(Required)

CAPTCHA

Please only press submit once. After successful completion, you will be redirected to the homepage. We will be in touch with you shortly!

Welcome to MedQuest Pharmacy!

Your Information

Practice Information

Licensing Information

Collaborating/Supervising Practitioner's Information (if applicable)

Compounded Medication Experience

Which Medications Do You Want to Prescribe Today?

Help us serve you better! What additional support can we offer?

Patients

Providers

About Us

Contact Us

Connect with us

Hours

Address