WELCOME

We received your request to open an account with Tailor Made Compounding.

Thank you for the opportunity to assist you with your compounding needs.

*Please follow the five simple steps to set up your account.

CLINIC INFORMATION

Clinic Name:
Address:
City State Zip Code

OFFICE CONTACT INFORMATION

Best Office Contact:
Contact's Position:
Email:
Clinic Phone:
Fax:

PHYSICIAN INFORMATION

Please take a moment to answer the question below to help.

If yes, how many?:

*Please fill out the following information for each physician that will prescribe through this account.

Physician Name:
Email:
Cell Phone:
NPI:
DEA:

CARDHOLDER INFORMATION

Name:
Billing Street Address:
City: State: Zip Code:
Phone #: Email:
  • Authorize Tailor Made Compounding to keep on file for future approved payments

CREDIT CARD INFORMATION

Card #:
Expiration: Security Code:
Card holder signature:
Date:
Our clinic would like for prescriptions to be handled as marked below:

Bill the clinic for prescriptions OR Bill the patients for prescriptions

Ship prescriptions to the clinic OR Ship prescriptions to the patient

BHRT
Pain Management
Anti-aging
Dermatology
Sterile
Other:
Nutritional

2. Who is your primary compounding supplier?
0 - $1,000
$1,000 - $5,000
$5,000 - $10,000
$10,000 +
a.
b.
c.
Notification preferences:
Notification emails:
Order Received
Invoice Created
In Dispensary
In Shipping
Has Shipped

Thank you for creating an account

You will receive a welcome email and account username and password within 1-2 business days. In the event you do not receive this information or should have issues or questions, please contact Chris Downs at cdowns@tailormadecompounding.com

P: 859. 887.0013 F: 859.406.1242 E : tory@tailormadecompounding.com tailormadecompounding.com