Physician WINFertilityRx e-Signature Registration

Important Information: Please have your DEA, NPI, license numbers and expiration days handy to complete registration.

Please Read: Each physician in your practice is required to register one time only. The physician can designate who in their practice may have permission to utilize the User Id and passwords.

Title
First Name	*	Last Name	*
Suffix
Home Address	*	Address 2
State	*	City	*
Zip Code	*
Year of Birth	*
Email	*	Confirm Email	*
Four digit PIN	*	Re-enter PIN	*
Practice Name
Practice Phone	*	Practice Fax	*
What is your preferred means of communication?		*

The following information is being requested to personally contact you in case of a registration error. Please enter at least one of the following.
Personal Phone
Personal Fax
Personal Cell/Pager

Primary Speciality	*
Secondary Speciality
State License Number	*
Issuing State	*
State License Exp. Date	(MM/DD/YYYY) *
DEA information and NPI is required to register.
DEA Number	*
DEA Schedule	II III IV V
NPI	*

Select a Secret Question	*
Secret Question Answer	*
Please safeguard your user credentials as you would any other personal information. Please contact Docusign immediately if you suspect fraudulent activity. DocuSign provides Frequently Asked Questions regarding eSignatures on their website https://www.docusign.com/products/electronic-signature.