“Know Your Customer” Questionnaire

Controlled substance orders will not be fulfilled until this questionnaire has been completed in full and reviewed by the Medical Purchasing Solutions Compliance Department.

IMPORTANT: This form must be completed by the DEA Registrant, POA or an authorized representative.

MPS Client Info

Doctor’s Info

 5. Primary Practice:

DEA Certificate

(As it appears on DEA Certificate)
10. DEA Registered Address (As it appears on DEA Certificate)

NOTE: If at any time your DEA standing, approved schedules or registered address changes you must notify MPS immediately.

State License

Additional Licenses (optional)

Please list any additional state licenses/registrations that cover controlled substances.

Practice Details

16. Days and hours of operation:

NOTE: If Power of Attorney forms are used, please send copies to compliance@medicalpurchasingsolutions.com

23. Of all the products you use at this location, what percentage is either a controlled substance, a non-controlled substance or a medical supply?

% % %
(Numbers only. Total must equal 100)

Medication Log

Enter the average quantity used of each medication per month and the average CC/MG's administered per patient.
Monthly Usage
Average dosage per patient
(specify CC/MG/ML’s)

Customer agrees and understands that Medical Purchasing Solutions may provide a copy of this questionnaire to the DEA, other federal agencies and any state regulatory agency where appropriate.

I certify that I am authorized to complete this form and that the information provided in this questionnaire is true and accurate to the best of my knowledge.

Not ready to submit the form?

Enter your email address and we'll send you a link to return to the form later.