Akina Pharmacy

Clinic Name(Required)

Clinic Website(Required)

Clinic Street Address Suite/Unit # City State ZIP Code

Clinic Phone(Required)

Clinic Fax

Clinic Fulfillment & Billing Preference(Required)

Select all that apply.

Select All

Bill and Ship to Clinic

Bill and Ship to Patient

Bill to Clinic/Ship to Patient

Undecided

Primary Contact Name(Required)

First Last

Primary Contact Email(Required)

Role at Clinic(Required)

Role at Clinic (Other)(Required)

Mobile Phone

Office Phone(Required)

Office Ext.

Primary Prescriber Name(Required)

First Last

Primary Prescriber Email(Required)

NPI(Required)

DEA

DEA required to submit a prescription that contains a controlled substance.

Prescriber Credentials(Required)

Would you like to add any additional prescribers?

Yes

Additional Prescriber Information

Please enter the full name, credentials, and NPI for each prescriber authorized to issue prescriptions from this location. The individuals listed below will appear as authorized prescribers in your online portal.

Column 1

Column 2

Column 3

Electronic Prescriber Portal Setup(Required)

If you select "a Single Login for Entire Clinic," you will receive a shared login for all staff, managed by the clinic’s primary contact. If you select "Separate Login for Each Prescriber," each prescriber will have their own individual username and password.

Single Login for Entire Clinic (assigned to primary contact)

Separate Login for Each Prescriber

Shipping Contact(Required)

First Last

Shipping Contact Email(Required)

Is the Shipping Address the same as the Clinic Address?(Required)

Yes

No

Shipping Address(Required)

Street Address Address Line 2 City State ZIP Code

Billing Contact(Required)

First Last

Billing Contact Email(Required)

Is the Billing Address the same as the Shipping Address?(Required)

Yes

No

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Consent(Required)

I agree to the Practitioner Agreement To Receive Delivered Drugs

Practitioner Agreement To Receive Delivered Drugs

Dear PROVIDER,

Pursuant to § 54.1-3420.2 B of the Code of Virginia, a pharmacy may deliver a dispensed drug order to a practitioner of the healing arts or other authorized person provided there is a written contract or agreement between the two parties describing the procedures for such a delivery system and the responsibilities of each party. By signing below, the practitioner’s office agrees to:

● Account for the security, accountability, integrity, and accuracy of dispensing or administering the prescription while in its possession. This includes, but is not limited to: securing the prescription so that it cannot be accessed by unauthorized personnel, as well as storing it with required storage conditions (i.e., room temperature, refrigeration, or freezer) to maintain the integrity of the medication,
● Provide proper counseling to the patient that the prescription is being administered to, per the practitioner’s professional judgment,
● Contact the pharmacy to cancel a prescription order if the patient, for any reason, is unable to receive the medication,
● Contact the pharmacy to arrange for the return of a drug to the pharmacy if the integrity of the drug has been compromised, or if the drug is not delivered to the patient for whom it was prescribed within 180 days,
● Recordkeeping for the return or proper destruction of any prescriptions that are not delivered to a patient. At a minimum, the recordkeeping of a returned drug must contain the date the drug was received, the name of the patient for whom the drug was prescribed, drug name, drug strength, drug dosage form, the drug’s lot number, the date the drug was returned, and the tracking number of the return shipment which will be provided by the pharmacy,
● Confirm that they are registered with the Virginia Board of Pharmacy to receive, store, and manage medications on-site as required by Virginia law,
● Retain a signed copy of this agreement in their records to ensure traceability and compliance with VABOP regulations,
● Assure confidentiality of patient health information (PHI), and
● Inform the patient and obtain consent for using this prescription process.

By signing below, the pharmacy agrees to:

● Account for the security, accountability, integrity, and accuracy of dispensing the prescription and during delivery of the prescription to its final destination. This includes, but is not limited to: securing the prescription so that it cannot be accessed by unauthorized personnel, as well as storing it with required storage conditions (i.e., room temperature, refrigeration, or freezer) to maintain the integrity of the medication,
● Provide a shipping return label to the provider for a drug that is not delivered to the patient and must be returned to the pharmacy for proper disposal or destruction,
● Recordkeeping for the return or proper destruction of any prescriptions that are not delivered to a practitioner or a patient,
● Assure confidentiality of patient health information (PHI), and
● Provide counseling for the patient, if requested and if not done so by the provider.

Practitioner/Authorized Representative Signature(Required)

Practitioner/Authorized Representative Title

Date(Required)

Pharmacy Representative Signature(Required)

Pharmacy Representative Title(Required)

Date(Required)

Will you be ordering Compounded Peptides?(Required)

Yes

No

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Projected Order Volume

Supplying accurate projected order volume enables us to meet and exceed service level expectations and enhance overall customer satisfaction. Thank you for your attention to this critical aspect of our partnership.

Semaglutide 5mg Vial (2.5mg/mL in a 2mL vial)

Number of Vials Per Week

Number of Vials Per Month

Semaglutide 10mg Vial (5mg/mL in a 2mL vial) - Projected Order Volume

Semaglutide 10mg Vial (5mg/mL in a 2mL vial)

Number of Vials Per Week

Number of Vials Per Month

Tirzepatide 20mg Vial (10mg/mL in a 2mL vial) - Projected Order Volume

Tirzepatide 20mg Vial (10mg/mL in a 2mL vial)

Number of Vials Per Week

Number of Vials Per Month

Tirzepatide 50mg Vial (25mg/mL in a 2mL vial) - Projected Order Volume

Tirzepatide 50mg Vial (25mg/mL in a 2mL vial)

Number of Vials Per Week

Number of Vials Per Month

Tirzepatide 60mg Vial (30mg/mL in a 2mL vial) - Projected Order Volume

Tirzepatide 60mg Vial (30mg/mL in a 2mL vial)

Number of Vials Per Week

Number of Vials Per Month

Sermorelin 6mg Vial (2mg/mL in a 3mL vial) - Projected Order Volume

Sermorelin 6mg Vial (2mg/mL in a 3mL vial)

Number of Vials Per Week

Number of Vials Per Month

Sermorelin 9mg Vial (3mg/mL in a 3mL vial) - Projected Order Volume

Sermorelin 9mg Vial (3mg/mL in a 3mL vial)

Number of Vials Per Week

Number of Vials Per Month

What you will need to complete the registration.

New Clinic Registration Form

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