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New Customer Set-Up Form
AC3-022621
7465 W. Sunset Road Suite 1200
Las Vegas, NV 89113
P: 800.995.4363
F: 800.985.4363
503A Patient-Specific Pharmacy
5710 Hoover Boulevard
Tampa, FL 33634
FDA-Registered
503BOutsourcing Facility
P: 800.995.4363
F: 800.238.8239
Tampa
Vegas
1. Complete, sign, and return the New Customer Set-Up Form and Credit Application Terms &
Conditions prior to the first order being shipped.
2. The complet
ed New Customer Set-Up Form can be faxed, mailed, or emailed to:
Mailing Address: AnazaoHealth Corporation
5710 Hoover Boulevard
Tampa, FL 33634-5339
Fax: 800.985.4363 (Attn: Customer Service)
E-mail: Customerservice@anazaohealth.com
As a new customer, you will automatically be enrolled in our online ordering system www.myAnazao.com
for e-commerce access which allows the prescriber or staff to place orders, add and edit patients, view
status of orders, check on delivery status, run reports and view organization/physician/staff settings.
If you wish to opt out of this enrollment, please check here.
Af
ter the requested information is processed, you will receive a welcome package within 3-7 business
days.
AnazaoHealth Corporation is authorized to provide nationwide services including the District of Columbia
and has successfully developed a national presence by providing its customers with high-quality,
innovative solutions that simplify and/or improve patient care. We look forward to building a long-term
relationship with your company and thank you for your business. Please contact our Customer Service
Department if you have any questions or concerns at 800.995.4363, Option 5.
New Customer Set-Up Form
AnazaoHeal
th Corporation AnazaoHealth - Las Vegas
503A Compounding Pharmacy 503B FDA-Registered
5710 Hoover Blvd. 7465 W. Sunset Road, Ste.1200
Tampa, FL 33634 Las Vegas, NV 89113
Monday – Friday Monday – Friday
8:00 am – 8:30 pm EST 8:00 am – 5:30 pm PST
Phone
: 800.995.4363
Option 1 – Pain Management Pharmacy Option 5 – Customer Service
Option 2 – Nuclear Medicine Pharmacy Option 6 – Accounting
Option 3 – Custom Pharmacy
Fax Orders:
Corporate & Pain Management Pharmacy – 800.985.4363
Nuclear Medicine Pharmacy – 800.697.5250 Custom Pharmacy – 800.238.8239
New Customer Set-Up Form
7465 W. Sunset Road Suite 1200
Las Vegas, NV 89113
P: 800.995.4363
F: 800.985.4363
503A Patient-Specific Pharmacy
5710 Hoover Boulevard
Tampa, FL 33634
FDA-Registered
503BOutsourcing Facility
P: 800.995.4363
F: 800.238.8239
Tampa
Vegas
AnazaoHealth Corporation is HIPAA compliant. All information is kept strictly confidential.
CUSTOMER INFORMATION Date
Name of Business/Practice_________________________________________________________
Address________________________________________________________________________
City, State, Zip code_______________________________________________________________
Phone_______________________________ Fax_____________________________________
Contact Person_________________________ Title_____________________________________
E-mail______________________________ Admin E-mail for myAnazao_____________________
Type of Organization: Corporation____ Partnership____ LLC ____ Other _______________________
Date business established_________________ Estimate annual volume of business $_____________
How did you hear about us? _____________________________________
BILLING INFORMATION
(If different from above)
Billing Address
City, State, Zip
A/P Contact A/P Email
A/P Phone A/P Fax
SHIPPING INFORMATION (Please use another sheet for multiple offices)
Clinic/Hospital or Physician’s office
Address
City, State, Zip
Contact Dept.
Phone
Ext
Fax
Special Shipping instructions
□ CUSTOM ACCOUNTS
PHYSICIAN INFORMATION (Please use another sheet for additional physicians)
Physician Name DEA #
Physician Name DEA #
Physician Name DEA #
□ NUCLEAR MEDICINE ACCOUNTS □ CENTRAL FILL PHARMACY
RAM License #
****** Note that all medications are compounded pursuant to the physician’s prescription. *******
AC3-022621
New Customer Set-Up Form
7465 W. Sunset Road Suite 1200
Las Vegas, NV 89113
P: 800.995.4363
F: 800.985.4363
503A Patient-Specific Pharmacy
5710 Hoover Boulevard
Tampa, FL 33634
FDA-Registered
503BOutsourcing Facility
P: 800.995.4363
F: 800.238.8239
Tampa
Vegas
If account is Credit Card Pay only, please skip to Payment Method
Name of Business______________________________Date_______________________________
Federal Tax ID#______________________________________ Duns# _______________________
Bank Reference: Bank Name___________________________ Bank Account_________________
Bank Contact_________________________________________Phone_______________________
BUSINESS REFERENCES: (LIST 3)
1.
Company Name___________________________________ Account #____________________
Address____________________________________________ Phone____________________
City, State, Zip code ___________________________________ Fax _______________________
2.
Company Name ___________________________________ Account #_____________________
Address____________________________________________ Phone____________________
City,
State, Zip code ____________________________________Fax ______________________
3.
Company Name ___________________________________ Account #_____________________
Address____________________________________________ Phone____________________
City, State, Zip code___________________________________ Fax ______________________________
Choice of Billing (Check all that apply):
Monthly Summary
Invoice per order Credit Limit Requested $
PO # required on original order? Yes No
All
customers will receive a month-end statement of open invoices
Payment Method (Check one option below):
Upon receipt of Invoice
Credit Card (charged at time of order)
Y
our credit card is kept on file and a receipt will be sent stamped “paid.”
MasterCard Visa AMEX Discover
C
redit Card # Exp. Date _________
____________________________________________________
Authorized Cardholder’s Signature
P
ayment Terms: All payments are due 30 days from date of invoice to:
AnazaoHealth Corpo
ration,
5710 Hoover Blvd., Tampa, FL 33634
The pe
rson(s) signing this Credit Application, Terms & Conditions form warrants that the above information is complete and accurate and hereby
agrees to the following terms and conditions:
1. The undersigned agrees to immediately notify AnazaoHealth Corporation of any change in ownership, form or business name of the entity.
2. This document will be as effective in photocopy or fax form as in the original.
3. The undersigned acknowledges that AnazaoHealth Corporation may limit or discontinue credit at its sole discretion and that the continued
extension of credit may require additional information from time to time.
4. The undersigned warran
ts that they have full authority to sign this agreement and obligate the entity hereunder.
5. The undersigned agrees that if all invoices are not paid when due, they will accrue late charges at the rate of 18% per annum or the maximum
rate allowed by law, whichever is less. If it is necessary to take legal action, jurisdiction shall be the State of Florida and the venue shall be
Hillsborough County, Florida. The undersigned agrees to reimburse AnazaoHealth Corporation for any attorney fees, court costs or other costs
of collection which may be incurred in its efforts to collect any past due debts.
6. There is a minimum compounding fee of $34.95 for sterile prescriptions and $29.95 for non-steri
le prescriptions.
Credit Application, Terms & Conditions
___________________________________________ ___________________________________________________
Signature
Date Signature Date
___________________________________________ ___________________________________________________
Signature Date Signature Date
AC3-022621
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1. Complete, sign, and return the New Customer

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Completed 14 September 2021

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