Akina Pharmacy

Let’s Get Your Clinic Set Up

This form takes just 5–10 minutes to complete. If you have questions at any point, feel free to email our team at ProviderSuccess@akinapharmacy.com — we're happy to help.

We recommend gathering the names and NPI numbers of your clinic’s prescribers before you begin — it’ll make things quicker and easier.”

Clinic Information

Clinic Name(Required)

Network Affiliation ID

Clinic Website

Clinic Address(Required)

Clinic Street Address Suite/Unit # City State ZIP Code

Clinic Phone(Required)

Clinic Fax

Practice Model(Required)

Practice Model - Other

Clinic Fulfillment & Billing Preference(Required)

Select all that apply.

Bill and Ship to Clinic

Bill and Ship to Patient

Bill to Clinic/Ship to Patient

Undecided

Primary Contact Information

Primary Contact Name(Required)

First Name Last Name

Primary Contact Email(Required)

Role at Clinic(Required)

Role at Clinic (Other)(Required)

Mobile Phone

Office Phone(Required)

Office Ext.

Prescriber Information

Primary Prescriber Name(Required)

First Name Last Name

Primary Prescriber Email(Required)

NPI(Required)

DEA

Prescriber Credentials(Required)

Would you like to add any additional prescribers?(Required)

Yes

No

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.

Prescriber Full Name

Prescriber Credentials (i.e MD, NP, DO)

NPI

Email

Electronic Prescriber Portal Setup

If you select “Single Login for Entire Clinic,” you’ll receive one shared login for all staff, managed by the clinic’s primary contact. If you select “Separate Login for Each Prescriber,” each prescriber will be assigned their own individual username and password.

Single Login for Entire Clinic (assigned to primary contact)

Separate Login for Each Prescriber

Would you like to prescribe controlled substances using the electronic portal?(Required)

Yes

No

DEA Expiration Date(Required)

IdenTrust Username(Required)

Shipping and Billing / Volume Projections

Shipping Contact(Required)

First Name Last Name

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 Name Last Name

Billing Contact Email(Required)

Will you be ordering Compounded Peptides?(Required)

Yes

No

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 Vials per Week

Semaglutide 5mg Vials per Month

Semaglutide 10mg Vials per Week

Semaglutide 10mg Vials per Month

Tirzepatide 20mg Vials per Week

Tirzepatide 20mg Vials per Month

Tirzepatide 50mg Vials per Week

Tirzepatide 50mg Vials per Month

Tirzepatide 60mg Vials per Week

Tirzepatide 60mg Vials per Month

Sermorelin 9mg Vials per Week

Sermorelin 9mg Vials per Month

Consent Form to Receive Delivered Drugs

Consent Form to Receive Delivered Drugs(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(Required)

Practitioner/Authorized Representative Name(Required)

Date(Required)

Complete Your Registration

Please click the Submit button to complete this registration.