Indivior Direct Pharmacy Account Set-Up

Direct Pharmacy Account Set-Up

^NSUBLOCADE^® Distribution Questions for Pharmacists

Questions or issues with the form? Please contact us by email at indiviorservice@cpdn.ca

* Indicates required fields

CONTACT NAME *

CONTACT EMAIL *

BILLING INFORMATION

Pharmacy/Office Name (for billing): *

Address 1 - Street Address *

Address 2 - Street Address

Address 3 - Department or Attention To

City *

Province *

Postal Code *

Payment Method * Indivior reserves the right to change the payment method chosen by customer. Payment terms are available upon request and are documented in the Terms & Conditions. Minimum order amount is required.

SHIPPING INFORMATION

same as BILLING

Store/Clinic Name (for delivery) *

Address 1 - Street Address *

Address 2 - Street Address

Address 3 - Department or Attention To

City *

Province *

Postal Code *

PRIMARY PHARMACIST INFORMATION

Primary Pharmacist Name (as it appears on license) *

Primary Pharmacist Email * Must NOT be a group email

Primary Pharmacist Phone # *

Primary PHARMACIST Licence # *

PHARMACY Licence # *

Pharmacist Licence Expiry Date *

Indivior’s approval for customer set-up is contingent upon the validation of primary pharmacist’s licence. If pharmacist’s licence is not valid upon review, account set-up will be suspended. Pharmacist will be notified and will have the opportunity to provide valid licence information and complete the validation/registration process.

REQUIRED IDENTIFICATION REFERENCES

1. Upload a PDF copy of ONE of the following reference documents:*

Current year receipt of annual dues payment from your College of Pharmacists
Current year certificate or license card from your College of Pharmacists
Declaration from a Guarantor
Official Letter

File must be PDF or JPG/JPEG format, less than 4MB total size.

2. Upload a copy of the Provincial Pharmacy Accreditation document/certificate, if applicable.

File must be PDF or JPG/JPEG format, less than 4MB total size.

Terms of Use

By submitting this application, I am stating that I have read, I understand and I agree to abide by the rules and regulations contained in the Terms and Conditions. I also certify that the information, statements and representations provided by me on this form are true and accurate to the best of my knowledge. I understand that presenting false information is a criminal offense and is punishable by law.

The Applicant acknowledges and agrees that all information is complete and accurate.
The Applicant acknowledges and agrees to the following conditions:
1. The assigned Private Key constitutes the Applicant’s legal digital signature, or digital ID, for the purposes of ordering controlled substances online from CPDN.
2. The Applicant agrees to protect his/her Private Key and to take all reasonable measures to prevent their loss, disclosure, modification or unauthorized use.
3. The Applicant is responsible for immediately informing CPDN of any loss, disclosure, modification or unauthorized use of their Private Key.
4. The Applicant acknowledges and agrees to use the Private only for the purpose identified in 2.1 above.
The Applicant and CPDN agree that the PRIVATE KEY will only be used for the purpose of verifying digital signatures for controlled substances orders through CPDN and will not be used for any other application.

I agree to the terms of use.

Please review all form fields to ensure accuracy before submitting.