Provider Onboarding Form - Southend Pharmacy

Tell Us About Yourself

First Name *

Last Name *

Clinic Name *

Clinic Address *

Clinic City *

Clinic State *

Clinic Postal Code *

Clinic Mobile Phone *

Website *

Clinic Office Phone *

Clinic Email *

Medical Provider Information

Provider NPI *

Provider type *

Supervising Doctor NPI Number(if applicable)

Additional Provider Names and NPIs

Terms and Conditions, Credit Card Authorization & Recurring Payments

Here’s How Recurring Payments Work:

You authorize Southend to charge to your credit card when you submit an order for a prescription product with us. You will be charged the Product Price plus all pass through shipping.

Recurring Credit Card Authorization

You may choose to have your prescription product orders automatically charged to your Visa, MasterCard, American Express, or Discover Card upon your submission of a prescription order to AP Max, Inc. d/b/a Southend Pharmacy (“Southend”) in your LifeFile account.

You will have the opportunity to add your Credit Card information in LifeFile when you send your first prescription, after that we will have it saved in your billing profile.

Credit Card Authorization *

I understand that AP Max Incorporated, d/b/a Southend Pharmacy, requires payment via credit card prior to shipment of all Product orders. I understand that I will have the option to make payment or require my patients to make payment upon my submission of Product orders.

Terms and conditions *

I attest that I have read and agree to Terms and Conditions.

Today's Date *

With my signature below , I agree to the terms and conditions and pricing, and if applicable, credit card authorization *

Clear

Questions? Contact Me!

Pharmacy Consultant: Chris Ruckel

Mobile number: (949) 235-3004

Email: CRuckel@southendpharmacystore.com