Qitek Labs and Customedico

Account Information
- Account Name*
- Phone*
- Fax
- Email*
- Address*
- City*
- State*
- Zip Code*
- Contact Name*
- Title*
- Hours*
Physician Authorization
By 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 2
- Date 2
  MM slash DD slash YYYY

Save and Continue Later

Account Information