Quantum Rx – Prescriber & Staff Onboarding

Step 1 of 2 – Prescriber Information

1. Prescriber Information

Form Completed By *

Doctor's First Name *

Doctor's Last Name *

Practice Name *

State *

Practice Address *

Prescriber State License # *

DEA Number *

NPI Number *

Account Email Address *

EPCS (Controlled Substances) *

Yes – Enable EPCS No – Legend drugs only

Enter any staff members you would like to have a login

First Name

Last Name

Position / Role

Trusted Agent? (a person or entity authorized to act on behalf of the Provider)

Yes No

Thank you!
All information received. Activation emails will be sent within the hour.