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Account Set-Up Request Form

Lifestyle Compounding specializes in providing healthcare providers with custom-compounded medications tailored to meet individual patient needs. Partner with us to deliver personalized treatments supported by rigorous safety protocols, third-party testing, and precise formulations designed to enhance patient care.

Provider Information

Your Practice’s Information

Shipping Address

Which therapeutic areas are you practicing in? Select all that apply.

Billing Information

I (we) hereby authorize Lifestyle Compounding to make charges to my payment method below. All records are kept in a secure file accessible to authorized personnel only. All payments are due upon receipt and unpaid balances may lead to late payment penalties and account closure.

Terms & Conditions

Shipping & Handling

It is understood that Lifestyle Compounding Pharmacy utilizes FedEx as methods of shipping. Lifestyle Compounding Pharmacy Charges a flat rate of 25 dollars Priority overnight as a standard to our clients  the prescription in which case the method will always be FedEx Priority overnight. Flat Rate 25 Dollars. Signature required delivery will be defaulted. It is understood that by choosing non-signature required delivery, the physician and/or patient is accepting full responsibility regarding the delivery of the prescription. In the event the shipping vendor indicates a successful delivery for a non-signature required package and the recipient states the package was not delivered, the patient and/or clinic will be responsible for payment of a replacement order.

Shipping & Handling

This Provider Agreement is by and between Lifestyle Compounding Pharmacy and “Prescriber” wherein.each of the parties agree as follows:

  1. Prescriber acknowledges this purchase is from Lifestyle Compounding Pharmacy for a specific patient of Prescriber’s practice.
  2. Lifestyle Compounding Pharmacy agrees that it provides patient specific compounded preparations to the Prescriber practice subject to the terms of this Provider Agreement.
  3. Each of the Parties agree to the following terms:
    1. Any patient specific compounded preparations prepared by Lifestyle Compounding Pharmacy arereceived by the Prescriber as an agent of the patient and shall not be re-dispensed tothe patient of the Prescriber or dispensed to any third party or entity.
    2. The Prescriber will provide all packaged literature to the patient for the medication usageinstruction and for the reporting of any adverse reaction of complaint in order to facilitateany recall of batches of compounded preparations.
  4. Prescriber acknowledges this purchase is from Lifestyle Compounding Pharmacy for a specific patient of Prescriber’s practice.

Get Started with Compounding

Contact us today to explore how Lifestyle Compounding can support your practice. Our team is ready to help you deliver customized, high-quality medications that meet the unique needs of your patients.

Learn More
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