Provider Registration — Formulation Compounding Center

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Same as Shipping Address

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Prescriber Info

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Person In Charge of Ordering *

DEA Number

NPI * 10-digit National Provider Identifier

👨‍⚕️ Supervising Physician

⚠ Your DEA number indicates you are a mid-level provider. You are required to provide your supervising physician's information. Controlled substance orders will be issued under your supervising physician's name.

Supervising Physician First Name *

Supervising Physician Last Name *

Supervising Physician NPI *

Supervising Physician DEA *

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💳 Payment Information

A credit card is required to place orders. Your card is securely tokenized — we never store your full card number.

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Legal Agreements

By signing below you agree that you have read the documents listed above and agree to be bound by their terms and conditions.

Master Service Agreement ▼

This Master Service Agreement ("MSA") is entered into by and between Formulation Compounding Center, LLC. ("Formulation Compounding Center") and the entity identified on the applicable electronic invoice as the purchaser of the Formulation Compounding Center Portal services, including its affiliates and subsidiaries (referred to collectively, as "Company"). It is considered effective upon completion of payment for the services.

FormuConnect (portal.formuconnect.com) offers access to a service-based online electronic prescription system that allows for electronic prescribing and other online tools and related services (also "Formulation Compounding Center Portal"), to assist individual physicians, their clinical staff, and their office staff (collectively, "End Users") to perform a variety of health care activities associated with electronic prescribing and electronic medication management.

I. Formulation Compounding Center Services. Formulation Compounding Center provides software applications, platforms, and services for electronic prescribing, medication management, and related products ("the Applications") for use by Authorized End Users.

II. Company Obligations. Company shall obtain consents or authorizations from patients to allow Company to use and disclose patient information and records through the Applications. Company shall ensure compliance with applicable laws and regulations.

III. Ownership. Subject only to the limited rights expressly granted to Company, Formulation Compounding Center has sole and exclusive rights to the Formulation Compounding Center Brand, the Application, and all related intellectual property.

IV. Confidentiality. Both parties agree that all Confidential Information is proprietary and shall remain the sole property of the disclosing party.

V. Compliance With Privacy Laws. The parties agree to comply with all applicable state and federal laws governing the protection of protected health information, including HIPAA and HITECH.

VI. LegitScript Certification. Formulation Compounding Center is a LegitScript-certified compounding pharmacy. LegitScript certification verifies that Formulation Compounding Center operates in compliance with applicable federal and state laws, maintains proper pharmacy licensure, and adheres to recognized standards of pharmacy practice. Formulation Compounding Center agrees to maintain its LegitScript certification in good standing for the duration of this Agreement.

VII. Data Security & HIPAA Compliance. Formulation Compounding Center employs industry-standard security measures to protect all protected health information ("PHI") processed through the FormuConnect platform. All PHI is encrypted at rest using AES-256-GCM encryption. All data transmitted between End Users and the platform is secured via TLS (Transport Layer Security). The platform maintains HIPAA-compliant audit logging, recording all access to and modifications of PHI for a minimum of six (6) years. Access to PHI is restricted to authorized personnel on a minimum-necessary basis, and all user sessions are protected by multi-factor authentication. Formulation Compounding Center conducts regular security assessments to ensure ongoing compliance with HIPAA Security Rule requirements.

XI. WARRANTIES AND DISCLAIMERS. TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, Formulation Compounding Center DISCLAIMS ANY AND ALL OTHER PROMISES, REPRESENTATIONS AND WARRANTIES, EITHER EXPRESS OR IMPLIED.

XII. LIMITATION OF LIABILITY. IN NO EVENT SHALL Formulation Compounding Center BE LIABLE FOR ANY SPECIAL, INDIRECT, INCIDENTAL, EXEMPLARY OR CONSEQUENTIAL DAMAGES, LOST PROFITS, OR BUSINESS INTERRUPTION.

XIV. Term and Termination. Either party may terminate the MSA if the other party has breached and failed to cure such breach within thirty (30) days of written notice. This MSA automatically renews annually unless notice is provided 60 days prior to renewal.

Notices to Formulation Compounding Center: 1511 Justin Rd, STE 106A, Lewisville, TX 75077 · info@formulationrx.com

I have read and agree to the Master Service Agreement

Consumer Privacy Policy ▼

This Privacy Policy describes Our policies and procedures on the collection, use and disclosure of Your information when You use the Service and tells You about Your privacy rights and how the law protects You.

Types of Data Collected: While using Our Service, We may ask You to provide personally identifiable information including email address, first and last name, and phone number. Usage Data is collected automatically when using the Service.

Use of Your Personal Data: The Company may use Personal Data to provide and maintain our Service, manage Your account, contact You regarding updates, and manage Your requests.

Retention: The Company will retain Your Personal Data only for as long as is necessary for the purposes set out in this Privacy Policy.

Security: The security of Your Personal Data is important to Us. All protected health information is encrypted at rest using AES-256-GCM encryption and transmitted over TLS-secured connections. The FormuConnect platform maintains HIPAA-compliant audit logs that track all access to protected data. User accounts are secured with multi-factor authentication, and access to personal data is restricted on a minimum-necessary basis. Formulation Compounding Center is a LegitScript-certified compounding pharmacy, maintaining compliance with all applicable federal and state regulations.

CCPA Rights: If you are a California resident, you have the right to notice, access, deletion, and non-discrimination with respect to your personal information.

Contact Us: info@formulationrx.com · Formulation Compounding Center LLC, 1511 Justin Rd, STE 106A, Lewisville, TX 75077

I have read and agree to the Consumer Privacy Policy

Terms and Conditions ▼

By accessing this website, you are agreeing to be bound by these website Terms and Conditions of Use, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws.

Use License: Permission is granted to temporarily download one copy of the materials on Formulation Compounding Center's website for personal, non-commercial transitory viewing only. You may not modify, copy for commercial use, reverse engineer, remove proprietary notices, or transfer materials.

Disclaimer: The materials on Formulation Compounding Center's website are provided "as is". Formulation Compounding Center makes no warranties, expressed or implied.

Limitations: In no event shall Formulation Compounding Center or its suppliers be liable for any damages arising out of the use or inability to use the materials on its website.

Governing Law: Any claim relating to Formulation Compounding Center's website shall be governed by the laws of the State of TX.

I have read and agree to the Terms and Conditions

I, _______________, agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound by this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically.

Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

I, , agree to the above.