5000 Birch St, West Tower Suite 3000, Newport Beach, CA 92660

New Account

New Account Page

Instructions for setting up a new account:

To order Endura-Kit™, please first set up your new account by downloading and completing the application that corresponds with your group (physicians or hospital pharmacies). By completing the application, you will stay in compliance with State and Federal requirements.

Once you’ve completed the application, please send it to our corporate office for review and approval.

It is critical that you fax your application to (800-537-0857) or scan and email your application to (admin@ventispharma.com) with a copy of your facility’s state license or physician state license.

If you prefer, you may also provide all this information to your Ventis Pharma sales agent.

If you have any questions, please call Ventis Pharma at 800-441-5841. We are happy to help you through this process.

Thank you for your interest in Endura-Kit™

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NUBRATORI RX

New Account Checklist

When submitting a new account please submit the following items by fax to (310) 347-4338 or email to info@nubratorirx.com

  




(please include this page when returning account paperwork)

Please Verify all questions are compeleted

NUBRATORI RX

Provider Profile Questionnaire










Are you licensed in any other states?

  
  
  
Physician's Facility Information:
(Please complete all questions as questionnaies with blank answers will not be processed)

Are you engaged in conducting business on the internet, i.e. by accepting and filling prescriptions without patient interaction?

Have you ever been convicted of a crime relating to the distribution of prescription drugs or a violation of any federal or state law?

Has your medical license ever been revoked, suspended, reprimanded,restricted, or placed on probation by a medical Licensing Board or other entity?

Have you ever had an application to practice medicine denied or refused by another medical licensing board or other entity?

Have you ever voluntarily surrendered a medical license, controller substance registration or DEA registration?

Have you resigned from any hospital,institution or health care facility in lieu of disciplinary action?

Are you currently under investigation or the subject of pending disciplinary action by any medical licensing Board, health care facility or other entity?

Is your medical lecense currently restricted in any way or haveyou ever been fined by any Medical Licensing board or other entity ?

Have you ever discontinued the practice of medicine for any reason for one month or more?

Have you ever been arrested,indicted,or convicted,plead guilty,or pled nolo contendere for violation of any federal, state, or local law (other than a minor traffic violation ) ?

Have you ever been known by any other name or surname?


Physicians Designation of Authorized Agent(s)




Designated Agent(s)


I certify that all the information I have provided is true, complete and correct




Designated Agent(s)


Original invoices will be sent to the provider, a copy of all invoices can be sent to the following address for accounting and payment if provided below:

I prefer electronic invoices.
I prefer paper invoices.

I certify that all the information I have provided is true, complete and correct

NUBRATORI RX

MEDICAL PROVIDER TERMS AND CONDITIONS OF SALES

Following are the Terms and Conditions of all sales and transactions between Nubratori Rx and medical providers, all hereinafter collectively referred to as “Provider.” By signing below, Provider acknowledges and agrees that all transactionbetween Provider and Nubratori Rx are subject thereto:

(initial)

2.     Provider acknowledges that all orders placed for Nubratori RX products are for patients that the provider believes will have a significant clinical difference over other commercial products on the market

3.     Provider agrees NOT to alter or tamper with the labeling or packaging of any Nubratori Rx product.

4.     Provider understands and agrees that pricing for Nubratori Rx products are subject to change without prior notice.

5.     Provider understands and agrees that some Nubratori Rx products are only sold in case sizes/quantities.

6.     Provider agrees to report any order discrepancies within two (2) business days.

7.     Provider agrees that any unused, expired, or unwanted Nubratori Rx products are to be disposed of according to all local, state and federal laws or regulations applicable to their licensure and the jurisdiction in which they conduct business.

8.     Provider acknowledges that Nubratori Rx Products cannot be returned.

9.     Provider must strictly abide by and observe all shipping, storage, return and non-circumvention policies of Nubratori Rx, and Provider further agrees to store and handle all products in proper and appropriate conditions and temperatures as per manufacturer labeling, industry custom, and applicable laws and regulations concerning such.

10.     Provider agrees to observe and abide by all local, state and federal laws, rules and regulations applicable their licensure and jurisdictions in which they conduct business

11.     Provider agrees to indemnify and hold Nubratori Rx harmless for all losses or damages suffered as a result of violations of these Terms and Conditions, or as a result of violation of any local, state or federal law or regulations concerning the possession, administering or dispensing of Nubratori Rx products

12.     Provider represents and confirms that it is fully insured for any liability or loss that may arise in connection with the purchase, possession, administering or dispensing of Nubratori Rx products

13.     Provider agrees NOT to display any Nubratori Rx product on their website or other electronic medium without Nubratori Rx’s prior written consent

14.     Provider agrees NOT to use or disseminate any marketing material concerning or advertisement relating to Nubratori Rx products without the prior, written consent of Nubratori Rx prior to such use

15.     Provider understands and acknowledges that in certain circumstances certain Nubratori Rx products may not be available due to manufacturing backorder issues beyond the control or scope of Nubratori Rx.

16.     Provider shall NOT attempt to, or actually, copy, imitate, or create any products similar, same as, or competitive against those offered by Nubratori Rx

17.     Provider is fully aware and acknowledges that all Nubratori Rx products are protected by patents and/or pending patents, and all labeling and marketing material is protected by copyright and/or trademark, and, further, Provider specifically agrees NOT to violate such patents, trademarks or copyrights, nor to engage in any activity inconsistent therewith by attempting to, or actually, copying or imitating any Nubratori Rx product, labeling, or marketing material

18.     All orders must be pre-paid by Provider prior to shipping from Nubratori Rx’s facility. For orders under $5,000, a credit card is acceptable means of payment. For orders over $5,000, 50% non-refundable deposit shall be wired at time of order and the balance must be wired by Provider to Nubratori Rx prior to shipping

19.     Accounts qualify to submit an application for credit after being established with Nubratori Rx for at least six months. Credit will be granted or denied pursuant to the unfettered discretion of Nubratori Rx, and subject to these Terms and Conditions, and any breach or violation of these Terms and Conditions by Provider shall also constitute a breach and violation of credit extended to Provider. Nubratori Rx requires one or more personal guarantees for the extension of credit to Provider and to guarantee Provider’s strict adherence to these Terms and Conditions.

20.     Nubratori Rx reserves the right to accept or reject any order. Furthermore, Nubratori Rx reserves the right to cancel any order or account at any time, without recourse, and pursuant to its unfettered discretion

21.     Nubratori Rx retains the right to change, modify or alter its Terms and Conditions of Sales at any time

22.     Any and all dispute arising from, or relating to, any sale or transaction between Provider and Nubratori Rx, or arising from or relating to these Terms and Conditions of Sales, shall be governed by California law and be brought exclusively in the Superior Court of California, County of Los Angeles. The prevailing party in such dispute, action or proceeding shall be entitled to their attorneys’ fees and costs, in addition to any other relief allowed by law or so granted by the court.


IT IS SO AGREED:


By: Robert Nickell

(Print name)

Its: CEO

(Corporate/organizational capacity or title of signer

NUBRATORI RX

381 Van Ness Ave Suite 1507, 1508 Torrance, CA 90501

Ventis Pharma P. 310.218.4153 F. 310.347.4338









Select Payment Type





Ihereby request and authorize Nubratori RX to apply payments of all invoices to the credit card listed above. Card member agreesto perform to obligationsset forth in the Card member’s agreement with the issuer. All sales are final. Errors must be reported to Nubratori RX within 72 hours of receipt for exchange. Payments are applied on date ofshipment.




BILLING INFORMATION FOR CREDIT CARD