“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)
(mm/dd/yyyy)
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. Please indicate your average "product mix". Meaning, of all the products you use at this location, what percentage is either a controlled substance, a non-controlled substance or a medical supply. (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)
Avg dosage per patient
(specify CC/MG/ML’s)
Alfenta/Alfentanil
Alfenta/Alfentanil
Alprazolam/Xanax
Alprazolam/Xanax
Alprazolam/Xanax
Alprazolam/Xanax
Brevital
Brevital
Diazepam
Diazepam
Diazepam
Diazepam
Ephedrine
Fentanyl
Fentanyl
Fentanyl
Fentanyl
Fentanyl
Fentanyl
Fentanyl
Hydrocodone/
Hydrocodone
Hydrocodone
Hydromorphone
Hydromorphone
Hydromorphone
Hydromorphone
Ketamine/Ketalar
Ketamine/Ketalar
Ketamine/Ketalar
Lorazepam
Lorazepam
Meperidine/Demerol
Meperidine/Demerol
Meperidine/Demerol
Midazolam
Midazolam
Midazolam
Midazolam
Midazolam
Midazolam
Morphine
Morphine
Oxycodone
Sufenta
Sufenta
Sufenta
Triazolam/Halcion
Triazolam/Halcion
Ultiva/Remifentanil
Ultiva/Remifentanil
Ultiva/Remifentanil
Zolpidem
Zolpidem
Zolpidem Tartrate



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.


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