Complete to begin your partnership with Southend Pharmacy

Healthcare Provider Onboarding

*** Please note that the individual filling out and signing this form must hold a valid medical license in each state in which you provide medical services, possesses the legal right to enter into a binding agreement, and accepts without limitation conducting this transaction electronically, disclaimers of warranties, damage and remedy exclusions and limitations arbitration and choice of Texas law. Such individual represents and warrants that he or she has the authority to enter into and bind the Provider to the Agreement terms.***

Tell us about yourself

First Name

Last Name

Clinic Name

Clinic Mobile Phone

Clinic Email

Website

Clinic Office Phone

Clinic Address

Clinic City

Clinic Postal code

Clinic State

License

Expiration Date

Provider NPI

Provider Type

Supervising Physician's NPI Number

Supervising Physician’s First Name

Supervising Physician’s Last Name

Click here to view the terms and conditions.

Here's How Recurring Payments Work:
You authorize Southend to charge to your credit card when you submit an order for a prescription product with us. You will be charged the Product Price plus all pass through shipping.

Recurring Credit Card Authorization
You may choose to have your prescription product orders automatically charged to your Visa, MasterCard, American Express, or Discover Card upon your submission of a prescription order to AP Max, Inc. d/b/a Southend Pharmacy ("Southend") in your LifeFile account.

You will have the opportunity to add your Credit Card information in LifeFile when you send your first prescription, after that we will have it saved in your billing profile.

Checkbox

I understand that AP Max Incorporated, d/b/a Southend Pharmacy, requires payment via credit card prior to shipment of all Product orders. I understand that I will have the option to make payment or require my patients to make payment upon my submission of Product orders.
I attest that I have read and agree to Terms and Conditions.
Yes, I consent to having Southend Pharmacy contact me via SMS messaging.

Today's Date

Signature2

With my signature below, I agree to the terms and conditions and pricing, and if applicable, credit card authorization.