Provider Authorization Form

To help us process your order efficiently, please submit your payment details using the secure form below. Your information is protected through our encrypted system.

This form is for providers to submit their payment information.

"*" indicates required fields

Cardholder Name

(as it appears on card)

Your Email Address*

Enter Email Confirm Email

Billing Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Clinic Name*

Card Number

Type of Card

Expiration Date*

CVV*

Authorization

Agreement*

I, the undersigned, authorize Emerald Compounding Pharmacy to charge my credit card This authorization is valid until I provide written cancellation.

Electronic Signature*

By entering my name below, I confirm my authorization for this transaction and consent to the secure processing of my payment information.

Date Signed*

Company

This field is for validation purposes and should be left unchanged.

+1 (321) 321-3313

Provider Authorization Form

Authorization

Secure Access

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