First Name *

Last Name *

Email address *

Phone *

Clinic(s) Name(s) *

Clinic Address *

City *

State *

Pharmacy Name *

Pharmacy Rep

Estimated Prescriptions per month *

Role *

What electronic health system (EHR) do you use? *

Prescriber Type *

Click all that apply

State of Licensure *

Click all that apply

State License Number *

NPI Number *

DEA Number

Agreement *

By clicking this box, I certify that I am a licensed healthcare provider authorized to prescribe medications. I certify that all information provided is true, accurate, and complete. I understand that controlled substances are prohibited through this platform. I acknowledge that I have read and understand all terms of this Agreement. I agree to maintain professional liability insurance as specified herein. I consent to credential verification and platform usage audits by AutoPilot.

Conditions *

By submitting this form, I accept all terms and conditions of the BAA Agreement described (below)