Quantum Rx – Prescriber & Staff Intake Form

Provider & Practice Information

Form Completed By *

Doctor's First Name *

Doctor's Last Name *

Practice Name *

Practice Email Address *

Provider Email Address *

Practice Phone Number *

Must be at least 10 digits. We'll auto-format as you type.

Practice Phone Ext

Practice Fax Number

If entered, must be at least 10 digits.

State *

Primary Practice Address *

Prescriber State License # *

DEA Number *

NPI Number *

Practice Management System

EPCS (Controlled Substances) *

Yes No

Additional Providers (Optional)

Add any additional prescribers that need onboarding.

Staff / Non-Provider Logins (Optional)

Enter any staff members you would like to have a login.

First Name

Last Name

Email

Position / Role

Location(s) for this staff member

Add one or more locations where this staff member will use the system.

Trusted Agent? (authorized to act on behalf of the Provider)

Yes No

IT Contact Information

Who should we contact for technical setup if needed, and other IT-related questions?

IT Contact Name

Title

Phone

Ext

Email

Signature

Please complete the intake form by signing below.

Terms & Conditions

By submitting this intake form, you confirm you are authorized to provide the information above on behalf of the practice/provider. You consent to receiving communications electronically related to onboarding, setup, and support.

Please review the full Terms & Conditions before agreeing.

I agree to the Terms & Conditions.

You must check this box to submit.