MEDICAL FREEDOM PHARMACY INTAKE

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? *
Additional Information
Should be Empty: