New Home Application
New facilities/homes will be added Monday through Friday. A minimum of 24 hours is needed to add a new home or facility. A pharmacy staff member will contact you when your facility has been set up and to ask any additional questions that may be needed.
Name of Home
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Administrator
First Name
Last Name
Email
example@example.com
I would like to be updated via email in regards to news and changes with Bremo LTC
Yes
Maximum Number of Clients
Provide Different Shipping Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What time do you administer daily medications at your faclity?
example 8AM
What times do you administer two times daily medications at your facility?
example 8AM, 8PM
What times do you administer three times daily medications at your facility?
example 8AM, 4PM, 8PM
What times do you administer four times daily medications at your facility?
examples 8AM, 12NOON, 4PM, 8PM
What time do you administer bedtime medications at your facility?
example 8PM
Please indicate preferred medication packaging style
Calendar Cards (single fill)
Multifill
Do you prefer paper or electronic MAR?
Paper
Electronic
Do you want physician order forms sent monthly?
Yes
No
Would you prefer PRN medications in bottles or count down cards?
Bottles
Count Down Cards
How is this home licensed?
MHMR
DSS Residential Care
DSS Assisted Living
Other
Current Pharmacy Provider
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Notes
Submit
Should be Empty: