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Analysis

To determine if point-of-care dispensing is right for your practice, please fill out and submit this form to receive a customized analysis and free DVD. Please use the Tab key to progress between fields. Pressing enter will submit the form immediately.

  Clinic Contact Information
Clinic Name:
Contact Person:
Contact Title:
Clinic Address:
City:
State:
Zip:
Phone Number:
Fax Number:
Email Address:
Web Address:

 
Clinic Statistics
# of Healthcare Providers:
# of separate sites:
# Patients per provider per day:
       
% patients with no prescription:
% patients with 1 prescription:
% patients with 2 or more prescriptions:
Average number of refills per prescription:
       
Pharmacy Issues:
How much time is spent daily per provider on Pharmacy issues? None15 Minutes
30 MinutesHourMore!?
  Number of pharmacy related phone calls per site per day? Calls/day.
  Number of pharmacy related faxes per site per day? Faxes/day.
 
What level employee handles the Pharmacy related issues? MD/DONPPA
NurseTechOther
  Do you have e-prescribing? Yes
No
  If so, what system?
       
Payers:
% Cash & Carry
  % Private Insurance
  % HMO/PPO
  % Workers' Compensation
  % Medicare
  % Others
List Clinic Specialties:
10 most common drugs w/ strength and count:
6 most common 3rd party payors with percentage of patients with each:
Comments:
Where did you hear of PTC:
If you heard about us from a PTC Representative, please give us their name:

    

 

 

 

 

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