Enrollment Form

Who is your pharmacy management system vendor? *

How did you hear about us? *Social mediaTrade showHeard from another pharmacyFrom my pharmacy software vendorOther

Please specify how you heard about us: *

Contact Information

This information is for internal use by Lumistry only and won't be displayed on your patient education page.

First Name *

Last Name *

Email Address *

Phone *

Your Pharmacy's NPI *

Pharmacy Information

This information will be displayed for patients on your patient education page.

Pharmacy Name *

Phone *

Email Address

Street Address *

City *

State *

Zip Code *

Website

Customization

Logo *I will upload my own logoUse a generic mortar & pestle logo

Please upload your PNG logo here:

No file chosen

Theme Color *

This is the color of your whitelabeled website, including buttons and any other webpage characteristics. You can customize elements to your brand color or use the default Lumistry Blue. (If you need help extracting a HEX value from your logo, a tool like this can help!)

Please use the default (Lumistry Blue)I will provide a custom HEX color value

Custom HEX Color *

Payment Preferences

Let us know how you plan to pay here. Please note that we will not ask for specifics on this form; more details will be requested via email based on your selection.

Payment via: *ACHCredit Card (3% convenience fee)

Agreement

By clicking below and submitting this form, you acknowledge: 1) you are familiar with your state’s requirements for providing patient medication information; and 2) you have reviewed the startup information and agreed to subscribe to Lumistry's Paperless Patient Education per the terms and conditions found at lumistry.com/client/terms-conditions and the subscription fee.