Quantum Rx – Prescriber & Staff Intake Form

Form Completed By *

Practice Information

Practice Name *

Practice 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.

Location Name *

Starts from the practice name. Change it if this site is called something else.

Primary Practice Address *

State *

Provider Information

Provider First Name *

Provider Last Name *

Provider Email Address *

Prescriber State License # *

DEA Number *

NPI Number *

EPCS (Controlled Substances) *

Yes No

Practices at *

Tick every practice location this prescriber works at. The list updates as you add or rename locations above.

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.

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.