Collective Agreement

Once Form is complete Copy and Paste into the contact box below to submit!

Pre-registration requests are usually processed within 24hrs. Some doctor's offices can take up to one week to verify recommendations letters. Please use this form if you are requesting delivery or if you are planning a visit in the next few days. We will contact you and let you know as soon as your pre-registration is complete.

Please make sure to bring your ID and recommendation ready for your first delivery. 
Contact Email *:
Name *:
 
First Name		  
Last Name		 Gender 
Date of Birth *:
 
Month		  
Day		  
Year
To order for delivery, please enter your address:

Street Address

City
ZIP
Phone Number
Military Veteran? 
How did you find us? * (must choose one) 
 Newspaper/Magazine Ad  Online Ad  Online Search  Event  Referral
 Other
 
Please specify
Doctor / Clinic Information
Doctor/Clinic Name *:
 Phone *:
 Please format the # correctly		 Verification Website: 
Patient ID *: 

Recommendation Expiration Date *: 
     
Month - Day - Year

Patient/Recommendation ZIP code *:
 (For verification purposes, the ZIP code on file with your doctor/clinic for your recommendation)

 Upload Patient Recommendation: (attach file, JPG/GIF/BMP/PNG/PDF only) NOTE: All images must be readable and in focus to be accepted. We recommend using a scanner rather than a camera phone. Files can not be larger than 2 MB in size. If you can not provide now, it will be required upon first delivery. If your doctor does not have 24-hr phone or web site patient verification, we recommend attaching your recommendation here.

NEW MEMBERS:: If you want, you can download this New Patient Agreement Form, fill it out, sign it, and bring it with you to your first visit or have it ready upon your first order. Otherwise, you can fill it out when you arrive here, or your Delivery Driver will have a blank copy that you can fill out at the time of delivery.

If you are a legal caregiver purchasing medicine for a patient, and you would like to fill out the form before your visit or delivery, please use this caregiver registration form.

Please make sure to also bring your Doctor's recommendation and ID with you to your first visit.