Medical Clinic Account Application

1. Medical Director & Billing Information

Medical Director Full Name *

Legal Company / Practice Name *

Company Bill-To Street Address *

City *

State *

ZIP Code *

Phone Number *

Medical Director Email *

Medical Director Credentials

Medical License Type *

State Medical License # *

Licensing State *

License Expiration Date *

10-Digit Federal NPI # *

DEA Registration # (Optional - for controlled substances)

DEA Expiration Date (Optional)

Attach Copy of Medical License & DEA Certificate (PDF or Image)

Max 15MB (.pdf, .jpg, .png)

3. Payment Terms & Finance Contact

Preferred Payment Method *

Finance / Accounts Payable Contact Name *

Finance Contact Phone *

Email for Invoices, Statements & Payment Confirmations *

Secure Credit Card Authorization Policy

For enhanced bank-grade security and HIPAA/PCI compliance, payment authorization forms are completed as the final onboarding step. Once your Medical Director credentials and practice licensing are verified and approved, an official Credit Card Authorization Agreement will be emailed directly to your finance contact to sign and upload to activate wholesale ordering access.

4. Submitter Attestation & Medical Director Signature Workflow

Medical Director Verification Protocol: As the practice submitter (e.g. Office Manager or Administrator), you are submitting this preliminary application on behalf of the practice. Upon submission, an automated verification request will be securely emailed to your designated Medical Director for their independent digital signature and authorization.

TERMS AND CONDITIONS: This application is for direct ordering of wholesale pharmaceutical products and is subject to acceptance from Apotheca, Inc. Pricing and product availability are subject to change. If this application is accepted, the account holder and its representatives agree to be bound by the terms and conditions prevailing at the time of each order. Background checks and primary source license verifications may be performed on all persons and medical licenses listed.

RETURN POLICY: Products must be in sealed, original container in re-saleable condition accompanied by a Return Authorization Form. Short-dated products or products exceeding expiration date may receive no credit or be subject to a restocking fee. Damaged items must be reported within 5 working days of receipt. All returns to be sent to Apotheca, Inc., 1622 N. 16th St., Phoenix, AZ 85006.

I declare under penalty of perjury that the information provided is true and correct, and I agree to the Apotheca Terms & Conditions of Sale, Credit Policy, and Return Policy.

Submitter Printed Legal Name *

Submitter Title / Role *

Submitter Email Address *

Date of Signature *

Submitter Digital Signature *

Draw signature using your mouse, trackpad, or touchscreen.

1. Medical Director & Billing Information

Medical Director Credentials

2. Facility / Shipping Location

Clinic Operating Hours & Delivery Schedule

3. Payment Terms & Finance Contact

4. Submitter Attestation & Medical Director Signature Workflow

Medical Clinic Account Application

1. Medical Director & Billing Information

Medical Director Credentials

2. Facility / Shipping Location

Clinic Operating Hours & Delivery Schedule

3. Payment Terms & Finance Contact

4. Submitter Attestation & Medical Director Signature Workflow

Application Submitted!