“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:

If ‘Other’ please describe:

6. Does your primary practice consist of traveling to multiple locations?

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?

19. Have you given Power of Attorney to any associates?

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?

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

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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.