Customer Signup Form

Customer Type

This wizard will take you through the process of creating an account in our system so you can order from us. If you are already a customer with ImprimisRx Pharmacy, please follow the instructions located in the email you received in order to access your account.
Let's get started!

Do you have...

Your Organization

Enter the name of your organization below. The field will autocomplete using data from the NPPES NPI registry.

Please enter organization name.

Your Contact Information

Enter your contact information below. We will use this information to set up an administrator login for your account with us.
Please enter your first and last name.
Please enter title.
Please enter email address.
Please enter a valid email address.
Email verification failed. Please enter a valid email.
This email address already exists in our system
Please enter phone number.
Phone number verification failed. Please enter a valid phone number.
Please enter a password.
Password can not be less than 8 characters.
Password can not be more than 50 characters.
Please confirm your password.
The passwords do not match.

Tell Us About Your Facility

Enter the name and address below for your facility.
Please enter facility name.
Please enter address line 1.
Please enter the city.
Please enter the state.
Please enter the zip code.

Who should be the contact person for this facility?

Please enter contact name.
Please enter contact number.
Please enter email address.
This email address already exists in our system.
Please enter a valid email address.

This person can add additional doctors for the facility

This person can select payment methods for facility

This person will be invited to create a login

Facilities

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No facility found.

Who at your facility can order?

Invite users at your facilities

We found these prescribers by matching their addresses with the address you entered. Click the checkbox next to their name and enter their email address if you would like to invite them to order.
You can manually add prescribers in a following step.
Facility Name: {{f.name}}
Please enter the email of prescriber.
Please enter the email of prescriber.
This email address already exists in our system

No prescriber found.

Invite Additional Prescribers

Would you like to invite additional users to order from your organization?
Please enter the name of person.
Please enter email address.
Please enter a valid email address.
This email address already exists in our system
Email verification failed. Please enter a valid email.
Please enter phone number.
Phone number verification failed. Please enter a valid phone number.

Invite Additional Prescribers

{{$index + 1}}.  {{item.name}} ({{item.email}})

No invitee found.

Your Organization

Organization already established.

Please contact to your administrator to sign-up.

Your Contact Information

A verification link has been sent to your email account.

Please click on the link that has been sent to your email account to verify your email and continue the sign-up process.

If you do not receive the confirmation message within a few minutes, please check your Spam folder just in case the confirmation email was delivered there instead of your inbox.

The verification link will expire after 48 hours.

Your Contact Information

A verification link has been sent to you email account.

Please click on the link that has been sent to your email account to verify your email and continue the sign-up process.

If you do not receive the confirmation message within a few minutes, please check your Spam folder just in case the confirmation email got delivered there instead of your inbox.

The verification link will expire after 48 hours.

Error

Sorry, we are unable to process your request at this moment.

Please try again or contact to our support.

Done!

Your request has been submitted successfully.

We will be verifying your signup information within the next 48 hours.

Almost Done!

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Facility #{{$index + 1}}:

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We will invite this person as a Facility Administrator
Facility Users:

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Invitee #{{$index + 1}}:

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