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For clinics & practices

Wholesale account

For clinics, med spas and medical practices. Get account pricing after a quick review.

Request a wholesale account

Complete the form below. Our team will review your facility details and set up your wholesale account with your pricing.

Facility Facility Name * Facility Address Facility Address (line 2)

Facility Phone * Facility Fax

Prescriber Medical Director / Prescriber *

Prescriber NPI * Prescriber DEA

Primary contact Primary Contact *

Phone * Email *

Secondary contact Secondary Contact

Phone Email

Delivery address (if different from facility) Delivery Address Delivery Address (line 2)

How did you hear about us? Source * Referred by (name, if applicable)

Authorization

By completing the Account Setup and Credit Card on File Authorization Forms, I hereby authorize Alpha Biologix LLC to deliver all patient prescriptions to the listed facility delivery address with all related charges billed to the credit card on file. The facility assumes the responsibility of delivering the medications to the patient and independently collecting any monies due to the facility for such services including the facility's pre-payment of the medications.

I have read and agree to the authorization above. *

A separate Credit Card on File Authorization form will be sent after we review your application. Please do not enter card details here.

Client Signature (type full name) * Date *

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Wholesale account

Request a wholesale account

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