Call us to get help now
(888) 222-2956
Patients
MQRefill
Provider Directory
Nutrascriptives
Providers
Prescribe With Us
SureScripts
eMedPlus Login
About Us
Careers
Apply Now
Contact Us
Refill Request
eMedPlus Login
Home
ยป
New Prescriber Registration
New Prescriber Registration Form
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Business Name
(Required)
Office phone
(Required)
Office fax
Business Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone
(Required)
Office contact
(Required)
First
Last
Office Email
(Required)
Enter Email
Confirm Email
State License Number
DEA Number
NPI Number
(Required)
Credentials
(Required)
MD
DO
ND
PA
NP
APRN
Other
Expected Start Date
MM slash DD slash YYYY
Specialty
Currently practicing BHRT?
Yes
No
Pharmacy Preferences
eMedPlus Account Set Up
Starter Kit
Marketing Kit
MedQuest Testing Services
Lab Account Set Up
Results Fax
Results Email
Kit to Office
Kit to Patient
Do you plan to do BHRT exclusively or incorporate into your practice?
What are the biggest challenges or roadblocks moving forward?
What are the top offerings/services/elements most important to you?
What would the ideal, perfect compounding pharmacy offer you?
What do you need help with to be successful with BHRT?
Do you have a best practice you would like to share with other health care professionals?
How did you hear about us?
(Required)
Best Day to Contact You
MM slash DD slash YYYY
Preferred Method of Contact
Phone
Email