Sign-Up Form – Wellness Pharmacy Practitioner Portal

How to create an account with us

We will need the Wellness Pharmacy new account form (page 2) completed. Please provide an email address to have on file so you can monitor tracking from UPS once the order has shipped – you can edit this email at any time (just call or email us!).
We will need a copy of the prescriber’s professional license.

Optional – if your state and/or license requires a collaborative agreement (page 3) to prescribe medication or if you have paperwork to show you have prescribing rights we will need this as well along with the collaborative physician’s license.

If you will be administrating compounds in your clinic or utilizing our bill to clinic/ship to patient option in your clinic we will need the physician agreement signed (page 4) (New York has a specific agreement form please request if need).
If EssentialPRO will be ordered you will need to fill out the EssentialPRO registration form (page 5) as well as this is a separate account from the pharmacy. For this product you can call in or email us your order you do not need to fax it in unless you already have it included on your patient fax form.
At your convenience please call the pharmacy at 800-227-2627 to provide a credit card to use as payment for orders shipping to your clinic/being billed to the clinic. Otherwise, there might be a delay as orders cannot be processed until we have billing information. If you ever need to change this just give us a call to update your form of payment.

Once the new account forms have been completed you are welcome to start prescribing your patient’s prescriptions.

All prescription orders will either need to be submitted through our on-line portal, faxed or E-prescribed. (Please note New York and Iowa require e-prescribe unless an exemption is granted from your state.) We cannot accept prescriptions by phone or email. If there are ever any issues with an order or prescription, we will reach out to your clinic. If we are unable to reach you, your order will not be processed until we have received communication from you.

If you prefer to fax in your patient prescriptions you can email us at info@wellnesspharmacy.com and we will create customized fax forms for you -Just let us know what medications you would like on the form.

After November 1, 2023 regulations have changed BUDs and the supply per month a patient can receive have changed. Please call for more information 800-227-2627

Each order will take approximately 48-72 hours to prepare and ship from the pharmacy.

New Account Setup
Clinic Name*
Practitioner Name*
Professional Degree or Certification*
Address*
Street Address Address Line 2 City State ZIP Code
Office Hours (for shipping)
Phone*
This field is hidden when viewing the form
Phone
Fax
This field is hidden when viewing the form
Fax
Clinic Email - for communication that will also include UPS tracking for clinic orders*
Online Portal Email * Optional – for the initial setup for ordering online via our online portal.
Once the initial portal setup has been created you will be able to add staff members at your convenience
NPI
How did you hear about us?
Will you be administering compounds (i.e. injectables, IVs, doxycycline, etc) in your clinics or utilizing our bill to clinic/ship to patient option in your clinic?*
We will need the attached statement signed and submitted. Please note: New York requires a different form.
- Valid Relationship Form
- Valid Relationship Form - New York
Attach signed relationship form here:*
Accepted file types: pdf, docx, png, jpg, jpeg, Max. file size: 10 MB.
If you would like to provide payment information for future use please call us at 1-800-227-2627.

**We cannot ship to CA, KY, ND, RI, SD, and WV**
Professional License File*
Accepted file types: pdf, docx, png, jpg, jpeg, Max. file size: 10 MB.
If you need to sign a collaborating agreement to prescribe medication OR if you have statements to submit to show proof of prescribing rights please attach them here.

Click here to download collaborative agreement
Upload Files
Drop files here or

Max. file size: 10 MB.
Register for EssentialPRO?*
Learn More (Clicking this will not affect your sign up process. It will open a new page and keep what you have filled out)
- Yes
- No
EssentialPRO Registration
Would you like to be added to our EssentialPRO physician's referrral list?*
- Yes
- No
Specialties or Area(s) of Interest
Your signature certifies that you are a licensed healthcare professional and that the issued password will be for the use of only yourself and your staff to place orders.
Signature*
Date*
MM slash DD slash YYYY

Wellness Pharmacy Practitioner Portal

How to create an account with us

New Account Setup

EssentialPRO Registration