Fill out the form below to authorize Qitek Labs and Customedico to setup your account for custom anti-infective therapy. Qitek Labs and Customedico for Custom Anti-infective Compound Therapy Account InformationAccount Name* Phone* Fax Email* Address* City* State* Zip Code* Contact Name* Title* Hours* Physician AuthorizationBy signing below, I authorize the pharmacist to review my patient lab results and make prescription therapy recommendations to my office. I will review each recommendation and determine that any substitutions within each anti-infective group are appropriate for my patient and are medically necessary. I will remove any medication that I deem inappropriate for the treatment of my patient.Name 1* NPI # 1* Credentials (MD/DO/DC PA/ ARNP) 1* Signature 1*Date 1* MM slash DD slash YYYY Name 2 NPI # 2 Credentials (MD/DO/DC PA/ ARNP) 2 Signature 2Date 2 MM slash DD slash YYYY Δ