MEDICAL FREEDOM PHARMACY INTAKE
Are you a pharmacist interested in joining AFLDS or do you own a pharmacy and want to help AFLDS patients?
Name of Pharmacist/Pharmacy
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does Your Pharmacy Provide Retail Services?
*
Yes
No
Does Your Pharmacy Provide Mail Order Services?
*
Yes
No
Does Your Pharmacy Provide Compounding Services?
*
Yes
No
In Which State Does Your Pharmacy Hold a License?
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Additional Information
Submit
Should be Empty: