Request access

1.0

Twenty three fields, six attestations, one signature

1Practitioner identityEight fields · all required

Legal first name ∗ Legal last name ∗ Credential ∗ NPI number ∗ State license number ∗ Licensing state ∗ License expiration date ∗ License document ∗PDF, JPG or PNG, up to 10 MB. Stored privately against the record and never in a public location.

2The practiceNine fields · one optional

Practice or entity legal name ∗ Entity type ∗ Practice website optional Practice street address ∗ City ∗ State ∗ ZIP ∗ Practice telephone ∗ Work email ∗ Role at the practice ∗

3Attestations Six · each affirmed separately

Each of these is stored individually with its exact wording and the date it was affirmed, so what was agreed to can be shown later even after the wording changes. That is why there is no single box that covers all six.

01I am currently licensed and in good standing in the state named above. 02I am requesting access in the course of my professional practice. 03I understand materials are supplied only pursuant to a valid prescription for an individually identified patient, dispensed by the licensed pharmacy of record. 04I will not resell, redistribute or transfer any material received. 05I understand Grade Bio provides no dosing, protocol or clinical guidance, and that all clinical decisions are mine. 06The information I have provided is true and complete.

4Signature The typed name is the signature

Signed this 31st day of August, 2026

Type your full legal name ∗ Date ∗

Recorded with this signature: the time in UTC, the network address it came from, the browser that sent it, and the version of the attestation text shown above. That set is what makes a typed name evidence rather than a formality.

Waiting on the first field.

What happens to this

1. Submitting opens a pending record. It does not open an account and it does not create a relationship.

2. A person checks the license against the issuing state board.

3. The NPI is looked up against the national registry. It corroborates; it never substitutes for the license.

4. A decision goes to the work email given, with a reason either way.

5. An approved account is tied to the licensed pharmacy of record that will dispense.

An NPI is not a licenseThe national registry issues a number to anyone who asks and never checks whether a license is live. The state license document and its expiration date are the actual control here, and a request without a readable document cannot be decided.

A flag is not a rejectionA free mail address or a residential looking address is marked for manual review, never auto rejected. A solo practice may legitimately have either.

Just have a question?Sheet G‑09 is ungated and never asks for any of this.

Held dataWhat is collected here, why, and for how long is set out in full on sheet G‑11.

GradeBio

Grade Bio is a brand of Mountain Brands LLC. Entity formation is pending and no registration has been filed. Correspondence to jv@gradebio.com or sw@gradebio.com.

Pre‑launch document Entity pending

This document opens
to licensed practice.

This site is limited
to licensed practice.

Nothing here
is approved
automatically.

Request access

Submitted. This opens a pending record, not an account.

A request has already been submitted from this browser.

The register

The company

Nothing hereis approvedautomatically.

Request access

Submitted. This opens a pending record, not an account.

A request has already been submitted from this browser.

The register

The company

Nothing here
is approved
automatically.