Account Setup

Thank you for your interest in APS Pharmacy in Palm Harbor, Florida. The pharmacy has reached capacity, but please complete this form and we’ll be happy to find the Belmar Pharma Solutions’ Compounding Center of Excellence that best suits your needs.

Account and Formulary Access

I am a:(Required)

Name(Required)

First Last

Your Title(Required)

Email(Required)

Phone

Practice Information

Prescriber's Name(Required)

Prescriber's Phone(Required)

Practice Name(Required)

Practice City(Required)

Practice State(Required)

Florida County(Required)

Compounded Medication Experience

Practice Tenure(Required)

Telemedicine(Required)

Currently Practicing BHRT?(Required)

Currently Using Compounds(Required)

Current Monthly Patient Count(Required)

Monthly Patients on Compounded Meds(Required)

Is Your Practice LegitScript Certified?(Required)

Which Medications Do You Want to Prescribe Today?

I Want to Prescribe(Required)

Hormone Pellets

Non-Sterile Medications (capsules, creams, tablets, troches)

Sterile Medications (injectables)

GLP-1s

Monthly Patients on Hormone Pellets(Required)

Monthly Patients on Non-Sterile Medications(Required)

Monthly Patient on Sterile Medications(Required)

Monthly Patients on GLP-1s(Required)

Do you need to ship GLP-1s to all 50 states?(Required)

Which states do you need to ship to?(Required)

GLP-1s – Cyanocobalamin/Semaglutide 1mg/1mg/ml

Are you ready to order Semaglutide today?(Required)

When will you place your first Semaglutide order?(Required)

How many 1mL vials of Cyanocobalamin/Semaglutide 1mg/1mg/ml a month?(Required)

How many 5mL vials of Cyanocobalamin/Semaglutide 1mg/1mg/ml a month?(Required)

GLP-1s – Tirzepatide 10mg/ml

Are you ready to order Tirzepatide today?(Required)

When will you place your first Tirzepatide order?(Required)

How many 1mL vials of Tirzepatide 10mg/ml a month?(Required)

How many 4mL vials of Tirzepatide 10mg/ml a month?(Required)

How Did You Hear About Us?(Required)

How Can We Help You?(Required)

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