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Application Inquiry

Please complete form below or call 800-438-2568

Customer Applications

Instructions:


1. Download and complete the applicable forms, print, and sign where indicated.


2. Obtain copies of the state license, facility license (if applicable) and DEA Registration (if applicable).


3. Return all documents either by fax to 310-220-2917 or email to sales@dvmed.com.

General Account Forms


  • Customer Application

    • Download Here


  • Know Your Customer Questionnaire (Required for customers ordering controlled substances)

    • Download Here

Pharmacy Account Forms


  • Pharmacy Application (Required for PHARMACY customers ordering controlled substances)

    • Download Here


  • Pharmacy Application (Required for PHARMACY customers NOT ordering controlled substances)

    • Download Here