Pharmacy and Clinic Inquiry Form

top of page

Home
About Us
- Board of Directors
Contact Us
- Partner to Receive Medications
- Donate Medication
Order Medications
FAQs
Swag Shop
Our Impact
Public Health Resources
Safe Medication Disposal
Press Room
Transparency
Careers
Donate Funds
More

Use tab to navigate through the menu items.

Clinics & Pharmacies: Inquire about partnering with RoundtableRx

Name of Clinic, Health System or Pharmacy

Type of health facility

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.

Powered by

info@roundtablerx.org

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

bottom of page

​Clinics & Pharmacies: Inquire about partnering with RoundtableRx

Thanks for submitting!

Clinics & Pharmacies: Inquire about partnering with RoundtableRx