New Customer Retail Application Form
Thank you for choosing HyGen Pharmaceuticals, Inc. We appreciate your business! To ensure a smooth and efficient process, please take a few minutes to prepare the necessary documents in advance.
Required
- Credit Application Form
- Copy of Customer’s State License
- Copy of Customer’s DEA License
- Terms and Conditions
- California POD (Required if pharmacy is located in California. )
Optional / If Applicable
- California POD (Required if pharmacy is located in California. )
- Duplicate and Deposit Faxed Checks ( Required if payment made by faxing copies of checks.)
- ACH Payment Authorization Form (Required if payment made by ACH.)
- WA State Resale Certificate –(Required if pharmacy is located in Washington State. )
- Prescription Drug Exemption Certificate )Required if pharmacy is located in Washington State)
Step-by-Step Application Process with Save & Resume Feature
The application form is designed with multiple sections to guide you through the process step by step, ensuring a smooth and user-friendly experience. At the end of each section, you can click the Next button to proceed or the Previous button to go back and review your entries.
For added convenience, we offer a Save and Resume feature. If you need to pause and continue later, simply click the Save and Resume link, enter your email address, and you will receive a secure link via email. This link allows you to pick up right where you left off and remains valid for 30 days.