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YOUTHFULMD
Training & Compliance
- Pellet Training
- Lab Compliance
ROI Calculator

Home
About
Services
YOUTHFULMD
Training & Compliance
- Pellet Training
- Lab Compliance
ROI Calculator

Practice/Organization Information

Legal Business Name *

DBA (if applicable)

Practice Type *

Medspa

Other

Specialty *

Tax ID (EIN) *

NPI Number *

State(s) Licensed to Practice *

Office Phone *

Office Fax *

Office Email *

Practice Website

Primary Practice Address

Address

Street Address *

City *

State *

Postal code *

Shipping Address (if different)

Street Address

City

State

ZIP Code

Authorized Contact Person

Full Name *

Title *

Direct Phone *

Email *

Provider/Prescriber Information

Full Name *

License Number *

DEA Number *

State DEA

DEA Expiration Date *

Board Certifications *

Pharmaceutical Ordering & Use

Will you be prescribing or dispensing medications? *

Yes

Do you have a valid medical license in each state where patients are located? *

Yes

Will you require compounded medications? *

Yes

Anticipated volume of monthly orders (units or patients) *

Types of medications you plan to order (check all that apply) *

Testosteron

Estrogen

Semaglutide

Tirzepatide

Peptides

Vitamins

Topicals

Other

Who will be responsible for placing orders? (Name/Title) *

Business & Billing Information

Accounts Payable Contact *

Phone *

Email *

Preferred Payment Method *

ACH
Credit Card
Check
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Billing Address *

Name on Account *

Additional Services (Optional)

Are you interested in receiving additional services? (Check all that apply) *

Functional Lab Testing

EMR/CRM Access

HRT Training

Business Consulting

Patient Marketing Support

Compliance & Acknowledgements

certify that all information provided above is true and accurate to the best of my knowledge

I acknowledge that all pharmaceutical ordering will comply with all federal and state laws, and that I am legally authorized to prescribe and/or dispense these medications

I understand that YouthfulMD GPO LLC does not provide medical advice or assume liability for treatment decisions made by the provider.

I agree to the terms of participation and will maintain good standing with my medical license, DEA, and all regulatory bodies relevant to the practice of medicine

I understand that all pricing, vendor contracts, and operational materials are confidential and may not be disclosed or shared outside of my organization.

I understand that administrative fees may apply for certain services provided by YouthfulMD GPO LLC and will be disclosed prior to enrollment

I authorize YouthfulMD GPO LLC and its partners to contact me via email or phone regarding membership, updates, and product offerings.

Signature *

Clear

Printed Name *

Date *

YouthfulMD offers turnkey HRT and wellness solutions for medical practices, combining in-office rapid diagnostics, phlebotomy-free blood collection, custom hormone therapy programs, pharmacy access, and full business support to help you grow your practice and optimize patient care.

Quick Links

Services

TAP™ Blood Collection

Contact info

Phone: +855-411-2225
Email: [email protected]
Address: 401 E Las Olas Blvd, Suite 130-135, Fort Lauderdale Florida 33301.

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