1. Please fill out our New Account Application.

  2. Choose a payment method:
    A. Net 30 - Business Credit Application
    B. Credit Card – Credit & Debit Card Authorization Form

  3. Send in your formulary of medications so we can provide a price quote.
    A. Please include the name, strength and pill size of the med.


Fax all documents to: 1-800-563-6967 - OR - eMail to:


Upon receipt of all completed documentation, an Aidarex Representative will contact you within 24 hours to walk you through the next steps to establish your account and ship your first order.