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Pharmacist Intake Form
Thank you for your interest in PHS! Please complete this intake form and our VP of Pharmacy, Dr. Melissa Smith, will contact you.
9
Questions
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1
Please Select One Of The Following Options:
Are you a clinical pharmacist already in clinic and wanting to implement PGx testing?
Are you an independent consultant wanting to collaborate with practices to implement PGx Testing?
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2
Name
First Name
Last Name
Suffix
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3
Company Name
If Applicable
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4
What State(s) Are You Licensed?
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5
Phone Number
Please enter a valid phone number.
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6
Email
example@example.com
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7
How Did You Hear About Us?
Precision Medicine Hero's
PHS Employer Group Program
Google
LinkedIn
Facebook/Instagram
Healthcare Provider
Other
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8
Please List Any Affiliate Group Partnerships:
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9
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