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Provider Onboarding

Set up your prescriber profile

INNOVATIVE COMPOUNDING PHARMACY will use this information to create your physician portal profile.

Email is the username. The provider will sign in with the email entered in this form after approval is complete.
Step 1

Provider identity

Capture the provider and practice details exactly as they should appear in the portal.

A valid phone number is required.
Step 2

Prescriber credentials

Keep the credential data clean. This step feeds the provider profile and license-related records.

Optional. Upload a photo or PDF of the state license. It will be saved in the provider Documents section.
Step 3

Billing and shipping

Billing writes to the physician profile. Shipping creates the provider's default portal shipping address.

Billing address
Shipping address
Step 4

Signature

Draw your signature to continue.

Signature Please sign in the area below.
Use your mouse, trackpad, or finger to sign.
Step 5

Authorization

Review the authorization details below and confirm to continue.

Authorization Review before continuing

I authorize INNOVATIVE COMPOUNDING PHARMACY to keep a signed credit card authorization on file for approved portal-related charges and administrative fees that I separately authorize.

I confirm that the information provided in this form is accurate to the best of my knowledge.

I understand that submitting this form serves as my acknowledgment and consent.

Signature preview
Step 6

Verification

Complete the final verification step before submitting this provider onboarding packet.

Human verification Complete the verification challenge before submitting the form.
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