New Client Assessment Form
Independent Pharmacy
PERSONAL DATA
Full Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Home Address
*
Phone Number
*
-
Area Code
Phone Number
Cell Number
*
-
Area Code
Phone Number
E-mail
*
Years in profession?
Professional Memberships?
PHARMACY INFORMATION
Name of Pharmacy
*
Address of Pharmacy
*
Phone Number
*
-
Area Code
Phone Number
Fax Number
*
-
Area Code
Phone Number
website
*
Number of years at present location?
*
Number of Owners for current location?
*
List professional seminars or conferences you attended in the last 12 months?
*
Have you completed any disease state management courses?
*
Please Select
Yes
No but I would like to.
No, but enrolled presently.
No and not interested.
List the disease state management courses you would like to participate in?
*
List pharmacy management seminars, courses, or conferences you attended in the last 12 months?
*
Describe your pharmacy location
*
Retail Strip
Inside Grocery Store
Professional building
Hospital out patient space.
Other
Describe your pharmacy neighborhood location
*
Rural
Metropolitan
Large Town
Hospital out patient space.
Other
How many independent pharmacies located in 5 mile radius of your store?
*
How many big box chain pharmacies located in 5 mile radius of your store?
*
List your stores hours of operation Monday to Friday
*
List your stores hours of operation Saturday and Sunday
*
Do you own more than 1 location ?
*
Yes
No
List other businesses that you have ownership in
*
Where do most of your customers come from now?
*
List the number of parking spaces assigned to your practice
*
Is your store located on a busy street?
*
Yes
No
What is the square footage of your practice?
*
Is there a space for OTC section?
*
Please break down the space allocation of your pharmacy
*
Please describe the categories of products you offer in your store
*
Do you provide delivery services
*
Yes
No
Who provides the delivery service for the store?
*
Do you provide vaccination services?
*
Yes
No
Do you have a separate consultation area?
*
Yes
No
Do you have a Waiting area?
*
Yes
No
Equipment and Software
How many computers does the pharmacy have?
*
Who is the internet service provider?
*
Do you have IT support? If yes, list service provider
*
If no, would you need IT service provider recommendation?
*
Who is the phone service provider?
*
Number of incoming lines to store?
*
What pharmacy software platform does the store use?
*
Dose the store subscribe to any other services to improve patient retention or clinical services? List all that apply
*
How many cash registers does the store have?
*
Whole Saler and Supplier Details
Discuss vendors for software, drugs, services, and all suppliers to the store.
How many drug suppliers does the pharmacy have?
*
Name of primary pharmacy drug supplier?
*
List other services your primary pharmacy drug supplier bills you for monthly?
*
What services would you like your primary supplier to provide you that they presently are not?
*
Number of deliveries per week from your drug supplier
*
Does your primary pharmacy drug supplier delivery on weekends ?
*
Does your primary supplier provide vitamins?
Yes
No
Does your primary supplier provide herbal products?
Yes
No
Does your primary supplier provide OTC?
Yes
No
List other services your primary pharmacy drug supplier bills you for monthly?
*
How often does your primary or secondary whole saler rep visit?
*
Name of secondary drug supplier
*
How do you find out about new products?
*
Do you dispense any high margin products?
*
Which supplier provides you high margin products?
*
List your top selling product?
*
List your lowest selling product?
*
Store Maintenance and Operations
Discuss the roles of you your staff and how you interact with your clients.
Do you inspect the outside of your store?
Yes
No
If the answer to the above question is yes, how often?
*
Is your store professionally cleaned?
Yes
No
If the answer to the above question is yes, how often?
*
How many staff members does the pharmacy have
*
Do you offer staff bonuses?
*
If the answer to the above question is yes, what is the criteria?
*
Do you have an employee manual or hand book?
*
Do you offer any employee benefits?
*
If the answer to the above question is yes, what is employee benefits are offered?
*
Do you require employees to sign a noncompete?
*
Do you have dress code?
*
Do you have written pharmacy procedures for workflow and operations?
*
If the answer to the above question is yes, provide a recent copy here:
Browse Files
Cancel
of
How are messages relayed to you?
*
What is your standard telephone answering process?
*
Example: Thank you for calling pharmacy 45 this is X how may I serve?
What is your after hours phone messaging process?
*
Are there regular staff meeting?
*
yes or no
If the answer to the above question is yes, what is covered?
*
Is there someone responsible for straightening the shelves in the Rx area? If yes insert name and title
*
Is there someone responsible for straightening the shelves in the OTC area? If yes insert name and title
*
Is there someone responsible for emptying trash? If yes insert name and title
*
Is there someone responsible for Cleaning the bathroom ? If yes insert name and title
*
Is there someone responsible for checking and sorting mail for manager/owner? If yes insert name and title
*
Is there someone responsible for sorting and reviewing faxes from doctor's offices or PBMs? If yes insert name and title
*
Is there someone responsible for making bank deposits? If yes insert name and title
*
Is there someone responsible for reconciling bank statements? If yes insert name and title
*
Is there someone responsible for reconciling EOB and income? If yes insert name and title
*
Pharmacy Sales Health
Answer these questions using pharmacy software reports to the best of your knowledge. Consultant will go through this information in great detail on the day of the onsite visit.
What is the average daily OTC sales?
*
What is the average weekly OTC sales?
*
What is the average monthly pharmacy OTC sales?
*
What is the average daily Rx sales?
*
What is the average weekly Rx sales?
*
What is the average monthly Rx sales?
*
What is the average prescriptions dispensed daily?
*
What is the average prescriptions dispensed weekly?
*
What is the average prescriptions dispensed monthly?
*
How long does it take to dispense a prescription for a patient waiting?
*
From receipt of the prescription, how long does it take to dispense a prescription for a delivery patient?
*
longest wait time
What percent of Rx monthly sales is contributed to cash sales?
*
What percent of Rx monthly sales is contributed to Medicare sales?
*
What percent of Rx monthly sales is contributed to Medicaid sales?
*
What percent of Rx monthly sales is contributed to Commercial sales?
*
What percent of Rx monthly sales is contributed to MTM services?
*
What percent of Rx monthly sales is contributed to specialty or compounding services?
*
Are your prescription prices competitive with your competition?
*
Are your OTC prices competitive with your competition?
*
Do you give price quotes over the phone?
*
Do you have a bookkeeping service?
*
Describe your bookkeeping process
*
Describe your record keeping process for hard copy rxs
*
Describe your record keeping process for invoices
*
Business Operations and Expenses
Provide monthly expenses for advertising (printing, postage and other marketing services)?
*
Provide monthly expenses for dues or memberships?
*
Provide monthly expenses for drug costs?
*
Provide monthly expenses for otc costs?
*
Provide monthly expenses for office supplies?
*
Provide monthly expenses for cleaning?
*
Provide monthly expenses for CEs?
*
Provide monthly expenses for donations or gifts?
*
Provide monthly expenses for pharmacy software?
*
Provide monthly expenses for phone and internet ?
*
Provide monthly expenses for clinical services?
*
Provide monthly expenses for employee salaries?
*
Provide monthly expenses for payroll taxes?
*
Provide monthly expenses for lights and other utilities?
*
Provide monthly expenses for rent?
*
Provide monthly expenses for loans?
*
Provide monthly expenses for loans?
*
Provide monthly expenses for liability business insurance?
*
Provide monthly expenses for malpractice insurance?
*
Provide monthly expenses for malpractice insurance?
*
Provide monthly expenses for other ?
*
list the item not listed
Provide monthly expenses for other ?
*
list the item not listed
Provide monthly expenses for other ?
*
list the item not listed
Customer Outreach and retention
Describe your marketing plan to recruit new customers
*
Do you keep emails, review phone calls for new business opportunity?
*
How often do you perform refill reminder calls?
*
How often do you perform follow up calls to confirm patients received their medication?
*
Do you perform birthday calls
*
yes or no
Do you have a customer appreciation program?
*
yes or no
Does your staff generate leads for new customer referrals?
*
yes or no
Do you have a physician recruitment program?
*
yes or no
Do you have a complimentary services?
*
yes or no
Do you provide news letters about your services monthly?
*
Yes or No
Do you speak at service clubs or organizations ?
*
Yes or No
Do you provide diabetes edu or other clinical education services to the ageing communities?
*
Yes or No
Client Strengths and Weakness
Describe your ability to manage your time
*
Describe your ability to promote your store
*
Describe your motivation to succeed as a store owner.
*
Describe your staff's ability to assist you succeed as a store owner.
*
What self improvement efforts have you made?
*
Describe your feelings about the present state of your practice
*
Be very honest and detailed
What is your highest personal motivational factor
power
money
time with family
peer impression
Describe your what you would like to change about your practice
*
Be very honest and detailed
Which of the following are your pharmacy's best current attributes?
Customer service
Front end products
Special Services
Other
What do you feel are your greatest strengths as an entrepreneur ?
*
Be very honest and detailed
Signature
Conclusion:
At the conclusion of this "exercise," you the practicing pharmacist will have a good idea about your store, your competition, your customers, your needs, your options to increase business, and short-comings that require immediate attention. I will provide you with a proposal for a map to improve your practice and create new revenue streams utilizing your present attributes and assist developing new ones. Best Wishes RX Consultants Plus: Dr. Patrece A. Jones, PharmD Consultant
Submit
Should be Empty: