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:

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:
  • Authorize Tailor Made Compounding to keep on file for future approved payments

CREDIT CARD INFORMATION

Card #:
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:
Order Received
Invoice Created
In Dispensary
In Shipping
Has Shipped

To establish your account we require a copy of the original documents listed below:

  • DEA Certificate (if applicable).
  • State Board of Pharmacy license or medical license.
FAX

THANK YOU FOR CHOOSING US FOR COMPOUNDING NEEDS. PLEASE WATCH THE VIDEO BELOW FOR AN INTRODUCTION ON HOW TO USE OUR PLATFORM, AND CHECK STATUS OF YOUR PRESCRIOTIONS, AND YOUR ORDER HISTORY.

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