Pharmacy Service Questionnaire
Contact Name
*
First Name
Last Name
Title
Medication Coordinator, Executive Director, etc.
E-mail
*
Phone Number
*
Format: (000) 000-0000.
Preferred Method of Contact
*
Phone
E-mail
Facility Name and Address
*
Facility Name
Street Address
City
State / Province
Postal / Zip Code
How many patients/residents are currently at your facility?
How many patients/residents is your facility licensed for?
Are you affiliated with any other healthcare organizations? If yes, what is the name of the organization?
If you are not, please leave blank.
Where is your facility currently receiving pharmacy services?
Please check below which services you would like to discuss.
Free deliveries
Multi-dose ribbon packaging
Blister packaging
Assistance with obtaining refills
Medication administration training
Electronic MARs
Printed MARs
24-hour On-call pharmacist services
How soon are you looking to make a change in the provider of your pharmacy services?
*
Immediately
Within a month
Within six months
Within a year or beyond
Submit
Submit form or
return to plazadrug.com
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