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Registration

Please complete the DEA information form below and set up your user account with Wall Medical to be able to purchase products on our website.

Once completed, we will review the information and send you a confirmation to be able to access the products….

DEA / User Registration

DEA Registrant Information

DEA Registrant Name *

DEA Registration Number *

DEA Registration Address *

DEA Registration Address

City

State/Province

Zip/Postal

DEA registration

Upload a copy of your current DEA registration **Optional

Maximum file size: 516MB

Due Diligence

Is any person other than the DEA registrant authorized to sign 222 blanks for this registrant? *

YES

If yes, please provide the printed names and a copy of a properly executed power of attorney granting this authorization.

Total number of practitioners at this location: *

Is the controlled substance activity for the entire clinic or just the individual registrant? *

Entire Clinic

Individual Registrant

Is the registrant the responsible person for all record keeping and inventories? *

YES

If not, please explain process and identify the responsible person.

Practice Type *

Typical ordering pattern for controlled substances

Daily

Weekly

Monthly

Other (Explain)Other (Explain)

Normal days/hours of operation:

List your days open and hours of operation *

I attest that the information provided in the above "know Your Customer" Due Diligence Form is true and accurate to the best of my knowledge. *

I AGREE

DEA Registrant Signature *

Clear

Use your mouse to sign (your finger on phone or tablet) or click the keyboard icon to type your name.

Date Signed *

Printed Name of DEA Registrant *

Wall Medial User Registration

This account is required to log in and purchase products from our website.

User Name - NO SPACES *

Email Address *

Password *

Questions?

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