Point of Care On the Road Intake Form
Organization Information
Organization Name
*
Primary Contact Name
*
First Name
Last Name
Title/Role
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Type
*
Agency
Pharmaceutical Company/Brand Team
Media Partner
Healthcare Organization
Health Non-Profit
Point of Care Experience & Objectives
Attendee Familiarity with Point of Care
*
No Experience
Low Experience
Experienced
Highly Experienced
Tell us more about your organization's experience with Point of Care, what you would like to learn more about, and your desired outcome for POC On the Road.
*
Audience Information
Estimated Number of Attendees
*
1-25
26-50
51-100
100+
Attendee Roles - select all that apply
*
Brand Team – Junior
Brand Team – Senior
Agency Planners – Junior
Agency Planners – Senior
Media Partners – Junior
Media Partners – Senior
Industry Experts / Thought Leaders
C-Suite
Program Interests
Desired Topic(s) - select all that apply
*
Point of Care Education / Best Practices
Measurement & Effectiveness
HCP & Patient Advocacy
Condition or Specialty Insights
Other
Preferred Format
*
Lunch & Learn - A focused, convenient session designed for a specific team, brand, or business need.
POC Strategy Session - A more in-depth session focused on advanced conversations about POC planning, integration, and measurement.
Point of Care Media Day - A broader program featuring relevant media partners, with POCMA managing outreach, agenda development, and coordination.
Candid Conversations - A facilitated roundtable bringing company stakeholders and leading experts together to openly discuss a specific challenge, condition, or industry issue and explore potential solutions.
Meeting Details & Logistics
Preferred Session Length
*
30 minutes
45 minutes
60 minutes
90 minutes
Half-day
Full-day
Preferred Meeting Format
*
In-Person
Virtual
Hybrid
Will food and beverage be required?
*
Yes
No
Is your meeting space equipped with AV?
*
Yes
No
Success & Timing
How will you measure the success of the event? Select all that apply
*
Attendance
Engagement
Survey Results
Planning Readiness
Other
Desired timing
*
ASAP - Approximately six weeks from POCMA's receipt of request
Future Date
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is there anything else you'd like us to know as we plan your Point of Care On the Road program?
Submit
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