**Note: If you do not intend on purchasing Controlled Substances you do not need to complete this section
Due to the increased abuse of controlled drugs we are required to perform our due diligence to help ensure that all transactions are valid and prevent any suspicious orders from being filled.
If you do not intend on purchasing controlled substances you may skip this section of questions. We are unable to fill any controlled substance orders without the following information completed.
If yes, please attach a copy of the procedures.
What percentage of the facilities pharmaceutical purchases are controlled substances?
What percentage of the facilities pharmaceutical purchases are non-controlled substances?
How many patients is your facility currently treating per month?
If answer is yes please attach list.
I declare under penalty of perjury that the foregoing information is true and correct.
Send a copy of your current DEA license with completed application.
Address on license must be the same as the address to which orders are being shipped.