Pharmacy and Clinic Inquiry Form

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Clinics & Pharmacies: Inquire about partnering with RoundtableRx

Name of Clinic, Health System or Pharmacy

Type of health facility * Required

Clinic (single location)

Clinic (multiple locations)

Health System

Pharmacy (single location)

Pharmacy (multiple location)

Other

Address

Contact Person's Name and Title

Contact Phone #

Contact Email

Why might your patients choose to use RoundtableRx for their medications? Select all that apply.

Non-citizen

Uninsured

Underinsured or High Deductible

Medicare "Donut Hole"

Temporary dropped insurance coverage

Desired medication not covered by insurance

Other

What are the most common medical conditions and/or medications you anticipate utilizing RoundtableRx for?

How many individual patients do you anticipate serving through RoundtableRx each month?

Comments/Questions

Thanks for submitting!

A RoundtableRx team member will be in touch with you shortly. If you are ready to partner immediately, please complete & submit a Notice of Participation.

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RoundtableRx operates the Minnesota Medication Repository Program as a 501(c)(3) non-profit organization.

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​Clinics & Pharmacies: Inquire about partnering with RoundtableRx

Thanks for submitting!

Clinics & Pharmacies: Inquire about partnering with RoundtableRx