Create a FarmaKeio Account

NEW ACCOUNT SETUP
Thank you for selecting FarmaKeio Superior Custom Compounding for your compounding needs. Please complete all the information below. Your FarmaKeio Account Team is available to answer any questions you may have about the application. We look forward to serving you and your patients.
Practice Name *
Practice Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Contact *
Primary Contact Email *
example@example.com
Provider Details
Name *

First Name Last Name Credentials
Provider's Email *
example@example.com
Provider's Mobile *
Please enter a valid phone number.
Medical License Number *
Upload Medical License Certificate *

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DEA License Number *
DEA Expiration *

Month Day Year
Date
Upload DEA License Certificate *

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Do you have a collaborating physician? *

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Collaborating Physician’s Name

First Name Last Name Degree
Collaborating Physician’s
example@example.com
Medical License Number
Upload Medical License Certificate

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DEA License Number
Upload DEA License Certificate

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PATIENT COUNSELING NOTICE
FarmaKeio® Superior Custom Compounding is committed to compliance with state and federal laws. We are aware that some patients reside in states differing from their prescriber. To ensure that all prescriptions received by FarmaKeio® are pursuant to a valid patient/doctor relationship, we require that the prescriber agrees that the following elements are met prior to sending us a prescription.

Prior to ordering, prescriber agrees to do the following:
1. In person and/or using live video conferencing equipment, prescriber will perform a documented patient evaluation, including history and physical examination, adequate to establish a diagnosis of patient’s conditionf or which any drug is prescribed. If the patient cannot travel to your office then you agree to supervise an exam given by a nurse or other professional and base your decision to prescribe the needed medications based on the results and the facts (symptoms, blood pressure, etc.) that have been verified by a qualified third party and observed by you electronically.
2. In person and/or using live video conferencing equipment, prescriber will maintain sufficient dialogue with patient regarding treatment options and the risks and benefits of treatment for patient’s condition.
3. Prescriber agrees to create a follow up care plan for patient.
4. Prescriber acknowledges and agrees not to prescribe a prescription to a patient based solely on an Internet/online questionnaire, consultation, phone call or email.
5. Prescriber will maintain contemporaneous medical records.
6. Prescriber will obtain either verbal or written informed consent from patient prior to delivery of service.
Prescriber agrees that all prescriptions sent to FarmaKeio® Superior Custom Compounding have met the criteria above, or are in full compliance with state and federal laws regarding a valid patient/doctor relationship.
Name *

First Name Last Name
Signature *

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CONTROLLED SUBSTANCE SECURITY REQUIREMENTS & RECORD KEEPING
FarmaKeio Superior Custom Compounding is committed to compliance with state and federal laws. To ensure that all controlled substances dispensed and/or shipped by FarmaKeio Superior Custom Compounding will be handled in accordance with these state and federal laws, we require that the prescribing physician acknowledges the following:
1. Prescriber acknowledges his/her responsibilities for compliance under Title 21, CFR Section 1301.7(a) requiring all registrants of controlled substances provide effective controls and procedures to guard against theft and diversion of controlled substances.
2. Prescriber acknowledges federal law and many states have controlled substance inventory, records, and prescription monitoring reporting requirements and such prescribing physician acknowledges to fulfill this duty in the lawful course of his/her professional practice.
Name *

First Name Last Name
Signature *

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CREDIT CARD INFO
Submission of this form confirms your request for payment by credit card. You agree to pay any and all amounts charged by FarmaKeio® Superior Custom Compounding to your credit card as specified below. In addition, you authorize FarmaKeio® Superior Custom Compounding to obtain approval from the credit card company listed below. I hereby authorize FarmaKeio® Superior Custom Compounding to charge my credit card account as listed below. I affirm that I am at least 18 years old and legally authorized to use the credit card account and number listed below. In addition, I understand and agree that any charges made to the account listed below are non refundable and agree to pay in accordance to my agreement with the specified card company, any such amounts charged by me both in the past and henceforth. Furthermore, I agree to hold FarmaKeio® Superior Custom Compounding completely and fully harmless from and against all claims of any type or nature whatsoever resulting from any charges made to said credit card account payment and will be billed to the credit card depicted below.

The card holder specified above agrees that FarmaKeio® Superior Custom Compounding will automatically bill the subscriber’s credit card upon completion of the prescription order unless other arrangements have been made specific to the above subscriber’s account.
Cardholder's name *

First Name Last Name
Card Number *
Expiration Date *

Month Day Year
Date
Security Code *
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cardholder Signature *

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NEW ACCOUNT SETUP

Provider Details

PATIENT COUNSELING NOTICE

CONTROLLED SUBSTANCE SECURITY REQUIREMENTS & RECORD KEEPING

CREDIT CARD INFO