Account Sign Up | OSRX Pharmaceuticals

Account Form

To be completed by a licensed doctor or doctor’s staff only.

Practice Name

Associated Doctors

Address

Contact Name

Grant this person access to the OSRX Prescriber Portal

Phone #

Which formulation(s) are you interested in prescribing?

What is your preferred method of prescribing?

How did you hear about OSRX?

Specify other:

PAYMENT INSTRUCTIONS

PHARMACY CALL PATIENT FOR PAYMENT

INVOICE FACILITY

Send invoice to:

SHIPPING INSTRUCTIONS

SHIP TO OFFICE

SHIP TO PATIENT

OTHER

Specify Shipping:

SHIPPING PRICES

FREE
3-5 DAY PRIORITY
SHIPPING TO PATIENT'S HOME

FREE
2-DAY FEDEX
SHIPPING TO THE OFFICE

$10
FEDEX
2-DAY PM

$20
FEDEX
2-DAY AM

$30
FEDEX
OVERNIGHT

$50
FEDEX
SATURDAY

PRODUCT PRICING

$40 PRED-KETOR 4ML

$40 PRED-GATI 3.5ML

$40 PRED-GATI-KETOR 4ML

$70 PRED-GATI-KETOR 7ML

$25 DEX-MOXI

$40 PRED-GATI-BROM 4ML

$70 PRED-GATI BROM 7ML

$40 PRED-BROM 4ML

$45 ATROPINE 0.01% 3.5ML

$45 ATROPINE 0.025% 3.5ML

$45 ATROPINE 0.05% 3.5ML

$50 TIM-LAT 3.5ML

$55 TIM-BRIM-DOR 3.5ML

$60 TIM-BRIM-DOR-LAT 3.5ML

IMPORTANT NOTICE CONCERNING PATIENT PAYMENT RESPONSIBILITY.
You have elected to have us bill your patients directly for their medication. Note medication will not be shipped to patient until they have fully remitted payment. We will make reasonable efforts to notify your office if we are unsuccessful in contacting one of your patients for payment.