Retail Clinician

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Personal Information

E-mail Address *

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First Name *

Last Name *

Title *

Company Name *

Shipping Information

Address *

City *

State *

Zip Code *

Country *

Other Contact Information

Phone

Fax

Retail Clinician Survey (required)

Do you wish to receive / continue to receive Retail Clinician free?
Yes
No

My primary business activity: *
In-Store Clinic at a Drug Chain
In-Store Clinic at a Supermarket Chain
In-Store Clinic at a Mass / Discount Chain
On-Site Clinic (not a chain retail location)
Headquarter location of a retail chain
Headquarter location of a clinic
Doctor�s Office / Hospital
Other (please specify)

My title is: *
Nurse Practitioner
Physician Assistant
Owner / Partner / President / Chairman / Corp VP / Other Executive
VP / Director of Pharmacy Operations
VP / Director of Real Estate / In-Store Leasing
VP / Director of Pharmacy Operations
Clinical Care Coordinator
Other (please specify)

The average number of patients my clinic writes in a day: *
Less than 10
11 - 20
21 - 30
31 - 40
41 or more

The average number of prescriptions my clinic writes in a day: *
Less than 10
11 - 20
21 - 30
31 - 40
41 or more

Your in-store clinic is located inside which chain retailer?

In lieu of a signature, we require a unique identifier used only for subscription verification purposes. Please tell us in what state you were born? *

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