Sign Me Up - KSPH | KloudScript: Community Led Specialty Pharmacy Care

First Name*

Last Name*

Title*

Email*

Pharmacy Legal Business Name*

Pharmacy DBA Name*

Owner's Name (If you are not the primary owner)

No. of Pharmacies*

Address Line 1*

Address Line 2

City*

State*

Zip*

Phone*

Fax

Year Established*

Pharmacy Location Type (e.g. Closed-Door, Warehouse, Chain, Strip Mall, etc.)*

Do you have a Sales Person on Staff?*

What do they sell or market?

Average Annual Revenue (Total for All Locations)*

Average Annual Number of Prescriptions Filled (For All Locations, All Prescriptions, not just Specialty)*

What is your Pharmacy Management System?*

Do you provide other Services at your Pharmacy? (To Select Multiple Services that Apply, Hold Ctrl and Select All that Apply)

Describe your current Specialty Business (include therapies you currently dispense)*

How many specialty pharmacy prescriptions do you fill on average each month in total for all locations you own / operate? (Specialty medications include medications to treat immunologic disorders, Multiple Sclerosis, Oncology, Hepatitis C, HIV, Osteoporosis (injectables only), Behavioral health (injectables only), etc.)

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