Initial Registration
What are you registering as *
Step 1
Select One
{{ classification.name }}
Please choose the business type that best describes you.
Step 2
{{ speciality.as_name }}
Step 3
Username *
Please Enter your DEA License number. This will be used on login
'I don't have a DEA', I can provide my HIN
{{ validateUnameMsg }}
Invalid DEA/HIN License
Password *
{{ checkPasswordStrength(newUserFormData.password.value) }}
{{ validatePwdMsg }}
Password should contain 6 or more characters
Confirm Password *
{{ checkEqualMsg }}
Password not matching
Email Address *
Enter valid email address
Business Trade Name *
Maximum {{ newUserFormData.legal_company_dba.errors.maxlength .requiredLength }} characters allowed.
Enter business trade name
Phone Number *
Enter valid phone number
How did you hear about {{sitename}}?
(Select All That Apply)
*
Friend/Peer
Email
Conference
Mailpiece
Magazine
Social Media
Google
Buying Group
PrimeRx Pharmacy Mgmt Syst
Select at least one.
What do you hope to achieve by using {{sitename}}?
(Select All That Apply)
*
Shop Hard to Find Items
Price Compare Negative/Low Reimbursement Items
Save $10k+ Per Month
Use {{sitename}} as Primary Rx Source
All of the Above
Select at least one.
New Member Training *
Would you like to schedule a 1 on 1 Onboard Training Session (Demo) to maximize your time and savings? *
Select One
No
Yes
Select an option
Would you like to schedule a quick training session on how to easily meet order minimums? *
Select One
No
Yes
Select an option
Signer Name *
Enter signer name
I have read and agree to these
Terms and Conditions
Please accept terms and conditions
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