“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

1. Account Number:

2. Company Name:

Doctor’s Info

3. Full Name:

4. Phone Number:

5. Primary Practice: CRNA
Dentist Anesthesiologist
Endodontist
General Dentist
Medical Ansesthesiologist
MD/DO
Naturopathic
Oral & Maxillofacial Surgeon
Orthodontist
Osteopathic
Periodontist
Plastic Surgeon
Surgeon
Other

If ‘Other’ please describe:

6. Does your primary practice consist of traveling to multiple locations? No
Yes

7. How many locations do you practice at?

DEA Certificate

8. DEA Registrant Name: (As it appears on DEA Certificate)

9. DEA Number: Expiration Date: (mm/dd/yyyy)

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

Street: City: State: Zip Code:

11. Approved Schedules: C2 C2N C3 C3N C4 C5

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

State License

12. State: License Number: Expiration Date:

Additional Licenses (optional)

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

13. Type: State: Lic Num: Exp Date:

14. Type: State: Lic Num: Exp Date:

15. Type: State: Lic Num: Exp Date:

Practice Details

16. Days and hours of operation:

Mon: Tue: Wed: Thur: Fri:
Sat: Sun:

17. How many practitioners administer controlled substances at this facility?

18. Have you authorized any associates to order/purchase controlled substances? No
Yes

19. Have you given Power of Attorney to any associates? No
Yes

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

20. How often are controlled substances ordered for this facility? Daily
Weekly
Monthly
As Needed
Other

If ‘Other’ please describe:

21. Average number of patients treated monthly with controlled substances in this facility:

22. List all suppliers you purchase controlled substances from other than MPS:

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?

Controlled Substances: % Non-controls: % Supplies: %

(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.

Medication Strength	Monthly Usage (units)	Average dosage per patient (specify CC/MG/ML’s)
Alfenta/Alfentanil 500MCG/ML 2ML AMP
Alfenta/Alfentanil 500MCG/ML 5ML AMP
Alprazolam/Xanax 0.25MG TAB
Alprazolam/Xanax 0.5MG TAB
Alprazolam/Xanax 1MG TAB
Alprazolam/Xanax 2MG TAB
Brevital 2.5GM VIAL
Brevital 500MG VIAL
Diazepam 5MG/ML 10ML MDV
Diazepam 2MG TAB
Diazepam 5MG TAB
Diazepam 10MG TAB
Ephedrine 50MG/ML 1ML SDV
Fentanyl 50MCG/ML 2ML AMP
Fentanyl 50MCG/ML 2ML SDV
Fentanyl 50MCG/ML 5ML AMP
Fentanyl 50MCG/ML 5ML SDV
Fentanyl 50MCG/ML 10ML SDV
Fentanyl 50MCG/ML 20ML SDV
Fentanyl 50MCG/ML 50ML SDV
Hydrocodone 5/325MG TAB
Hydrocodone 7.5/325MG TAB
Hydrocodone 10/325MG TAB
Hydromorphone 1MG/ML 1ML AMP
Hydromorphone 2MG/ML 1ML VIAL
Hydromorphone 2MG/ML 20ML MDV
Hydromorphone 10MG/ML 50ML SDV
Ketamine/Ketalar 10MG/ML 20ML VIAL
Ketamine/Ketalar 50MG/ML 10ML VIAL
Ketamine/Ketalar 100MG/ML 5ML VIAL
Lorazepam 1MG TAB
Lorazepam 2MG TAB
Meperidine/Demerol 25MG/ML 1ML SDV
Meperidine/Demerol 50MG/ML 1ML SDV
Meperidine/Demerol 100MG/ML 1ML SDV
Meperidine Solution 50MG/5ML SOLN 500ML BTL
Midazolam 1MG/ML 2ML VIAL
Midazolam 1MG/ML 5ML VIAL
Midazolam 1MG/ML 10ML VIAL
Midazolam 5MG/ML 1ML VIAL
Midazolam 5MG/ML 2ML VIAL
Midazolam 5MG/ML 10ML VIAL
Midazolam Syrup 2MG/ML 118ML BTL
Midazolam Syrup 2MG/ML 5ML U/D CUP
Morphine 4MG/ML 1ML SDV
Morphine 10MG/ML 1ML SDV
Oxycodone 5-325MG TAB
Phentermine 15MG CAP 100/BTL
Phentermine 37.5MG TAB 1000/BTL
Sufenta 50MCG/ML 1ML AMP
Sufenta 50MCG/ML 2ML AMP
Sufenta 50MCG/ML 5ML AMP
Triazolam/Halcion 0.125MG TAB
Triazolam/Halcion 0.25MG TAB
Ultiva/Remifentanil 1MG/3ML SDV
Ultiva/Remifentanil 2MG/5ML SDV
Ultiva/Remifentanil 5MG/10ML SDV
Zolpidem 5MG TAB
Zolpidem 10MG TAB
Zolpidem Tartrate 12.5MG ER TAB

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.

Full Name

Title

Phone Number

Date

Not ready to submit the form?

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

Your email:

A copy of your current Federal DEA Certificate and State License is required for all MPS Accounts. You may fax them to (800) 351-0834 if you are creating a new account or need to submit an updated license. New clients and clients who have not yet established approved open credit terms with us must provide a valid credit card with all orders. Please note that order processing will be delayed until a valid payment method is established. Medical Purchasing Solutions, LLC sells pharmaceuticals and medical supplies to licensed medical professionals. We do not sell pharmaceuticals or medical supplies to the general public.