New Account Request

Tell us about your practice

Where health and partnership meet.

Primary contact

Let us know who we'll be working with.

First name

Last name

Work email

Direct phone

Contact role

Contact title (if other)

Practice profile

Tell us about your organization so we can customize onboarding.

Practice name

Practice website (optional)

Address

We use this for shipping logistics and service eligibility.

Street address

Suite / unit (optional)

City

State

ZIP code

Operational snapshot

Help us understand your current patient volume and workflows.

Number of practice locations

Number of prescribers

Patient care model

In medical office

Telehealth

Both

Average patients per day

0-10

11-50

51-100

101-250

251-500

500+

Affiliation

Let us know if you partner with a network or franchise.

Is your practice part of a network or franchise?

Yes

No

Network or franchise name

Attribution

Tell us how you found Hallandale Pharmacy.

How did you hear about us?

Other details

Workflow & notes

Optional context to help our team support you faster.

Therapeutic interest areas

Select all that apply so we can route resources to the right team.

Custom Compound

Dermatology

Fertility

Hormone Replacement

Injectable Supplies

IV Therapy & Supplements

Nausea

Ophthalmology

Peptide Therapy

Sexual Wellness

Shipping

Thyroid

Vitality

Vitamins/Supplements

Weight Management

How do you typically submit prescriptions?

Describe your workflow

Medications of interest (optional)

Anything else we should know? (optional)