Get Physician Registration Form -

Filling out the Physician Registration Form is a crucial step for medical professionals participating in the Physician Success Program. This guide is designed to provide clear instructions on completing the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the Physician Registration Form and open it in your editor.
2. Begin by reading the materials in the Physician Success Program. Check the box to confirm your understanding.
3. Review the indications for ® (sodium oxybate) and check the box confirming your understanding that it is approved for specific narcolepsy-related conditions only.
4. Acknowledge that safety for doses exceeding 9 g/day has not been established by checking the designated box.
5. In the 'Prescriber’s Name' field, print your full name clearly.
6. Enter your professional designation (MD, DO, etc.) in the appropriate section.
7. Provide your full street address, including both Street Address 1 and Street Address 2, if applicable.
8. Include your city, state, and ZIP code in the designated fields.
9. Fill in your phone number and fax number accurately.
10. Enter your DEA number in the specified section.
11. Lastly, provide the name of your office contact.
12. After ensuring that all fields are filled out completely and accurately, save your changes. You can then download, print, or share the completed form.

Complete your Physician Registration Form online today to ensure efficient processing.