New controlled substance.jpeg

Controlled Substance Application

Authorization to Purchase Controlled Substances

**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.

Does your facility have procedures in place to monitor or prevent addiction and diversion of controlled substances?
Select File
Max File Size 15MB

If yes, please attach a copy of the procedures.

Do you conduct random unannounced drug testing for your employees?

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?

Does this facility order for, transfer, supply, distribute or sell controlled pharmaceuticals to any other practitioners or facilities?
Select File
Max File Size 15MB

If answer is yes please attach list.

Does this facility fill prescriptions issued by the practitioners based solely on an on-line questionnaire without a medical examination or bona-fide doctor-patient relationship?
Does facility sell or ship pharmaceuticals by mail order?
Is facility complying with the laws of the state in which it is administering/dispensing controlled substances?

I declare under penalty of perjury that the foregoing information is true and correct.

Signature of Responsible Party

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.

Toll-Free Phone: (800) 850-1657

Local Phone: (540) 375-9380

Fax: (800) 361-6984

1640 Roanoke Blvd

Salem, VA 24153

  • Grey Facebook Icon
  • Grey Twitter Icon
3fc0afff-122f-4456-914f-e92eaf03e382-b1f