Pharmacy Marketing Sign Up Form

Please use the form below to sign up for our Compounding Pharmacy Referral Program.  This is not a contract and the information collected will only be used for the design and content of your web presence.  Due to quality standards only members of PCCA (Professional Compounding Centers of America) will be considered.  You will be contacted by phone for contract and billing information. 

Here is a brief description of the three packages we offer:

Basic Pharmacy Web Presence $25/month (less than $1 per day)

Your pharmacy will receive a basic individual web page which will contain your store name, address, phone number, fax number, hours of operation, link to your e-mail address, link to your pharmacy website (if applicable), and list of your staff members.

Full Page Web Presence (Deluxe Package) $60/month

Your pharmacy will receive a full web page with all of the information that you included in the spaces above listed on the page.  This will also include a link to your e-mail address and your store's web site (if applicable).  There will also be a link on your web page to a completely separate page with a full map of your location and additional contact information.

Full Page Web Presence + Patient Care Module (Advanced Package) $95/month

Your pharmacy will receive a full web page with all of the information that you included in the spaces above listed on the page.  This will also include a link to your e-mail address and your store's web site (if applicable).  In addition the advanced package includes patient access to our BHRT follow up form, Female Hormone Evaluation, and Male Hormone Evaluation.  Patients searching on our web site and patients that you are currently working with  can access these forms and the results are sent directly to your e-mail.  This patient care module saves your patients time and simplifies the BHRT follow up process.

Sections with a "*" symbol are required.

Pharmacy Name*

Pharmacy Address*

City*   Zip Code*  State*

E-Mail*  Web Site

Phone Number*   Fax Number*

Hours Of Operation*

Pharmacy Mission Statement

Please Provide Us With General Information Regarding Your Pharmacy (pharmacy history, your goals, and any other information you want your patients to know):*

Message From The Pharmacist (should be a direct statement from the pharmacist to his/her prospective patients). *

Services Your Pharmacy Offers:*

Honors/Store Recognitions:

Staff Members and Descriptions:*

Please List 2 Doctors That You Recommend For BHRT.  List Doctors Name, Address, and Phone Number.  Additional Doctors Can Be Added For $5 Per Month.

Package Options (Choose 1 Option Only)*

Basic Pharmacy Web Presence

6 Months - $50 one time set up fee + $25 per month

12 Months - FREE set up fee + $25 per month (save $50)

or

Full Page Web Presence (Deluxe Package)

6 Months - $75 one time set up fee + $60 per month

12 Months - $25 one time set up fee + $60 per month (save $50)

or

Full Page Web Presence + Patient Care Module (Advanced Package)

6 Months - $125 one time set up fee + $95 per month

12 Months - $50 one time set up fee + $95 per month (save $75)

Payment Options - Would You Be Interested In Paying With Credit Card or Check.  We Will Contact You By Phone For Billing Information For Security Purposes.*

Credit Card (You will automatically be billed at the first of each month)

Check (Entire amount due at the start of the program)

Questions/Comments For TestMyHormones.com

Name Of Pharmacy Owner/Point Of Contact*

Please review your information prior to pressing the submit button.  The information will appear on your web page as you have entered it on this form.

E-mail the Webmaster with questions or comments about this web site.        © 2007    - Helpful Links

NOTE: California Residents - Business and Professions Code 1246.5 Requires That Any Test that has not been approved by the Federal Food and Drug Administration for sale to the public without a prescription as an Over-The-Counter Test kit must be ordered by a Licensed physician acting on a patient's behalf.  All orders for test kits within the state of California

NOTE: New York State Residents New York State health law prohibits the testing of certain specimens collected in or mailed from New York, and prohibits the transmission of data from our laboratory to NY physicians or residents. Therefore, direct receipt of lab results for NY residents is not possible.

International Residents & Orders:  Extra shipping charges may be added for international orders.  Patients will be contacted by e-mail or telephone to approve charges.