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Get Intravitreal Injection Leiters Compounding 408 288-8252
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How to fill out the Intravitreal Injection Leiters Compounding 408 288-8252 online
This guide provides detailed instructions for filling out the Intravitreal Injection Leiters Compounding form online. By following these steps, users can ensure accurate and efficient submission of their orders.
Follow the steps to complete the Intravitreal Injection order form online.
- Press the ‘Get Form’ button to access the Intravitreal Injection Leiters Compounding 408 288-8252 form in the online editor.
- In the 'Prescriber's Full Name' field, enter the complete name of the prescriber placing the order.
- Fill in the 'DEA#/NPI#' field with the prescriber's Drug Enforcement Administration and National Provider Identifier numbers if applicable.
- Indicate the 'Date Ordered/Faxed' to record the date of your submission.
- In the 'Shipping Information' section, select one of the shipping options provided, such as 'FedEx Overnight (on ice)' or any other option suitable for your needs.
- Provide the 'Name of Facility', 'Shipping Address', 'City', 'State', and 'Zip Code' to ensure accurate delivery.
- Enter a 'Phone Number' and 'Contact Name' for the shipping confirmation.
- In the 'Billing Information' section, fill out your 'Billing Name', 'Billing Address', 'City', 'State', and 'Zip Code' appropriately.
- Include a 'Phone Number' for billing inquiries.
- Enter your 'Credit Card or Purchase Order #' and 'Leiter's Customer #' if available.
- Complete the payment information by providing the 'Exp. Date' for your payment method.
- If you prefer not to receive updates from Leiter's Compounding via email, check the designated box.
- After reviewing your form for accuracy, save your changes, and choose to download, print, or share the completed form.
Complete the Intravitreal Injection order form online for a seamless ordering experience.
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