Pharmacy and Clinic Inquiry Form

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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

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