Get in Touch! | 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)*
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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KloudScript, Inc.

17W755 Butterfield Road, Suite 102
Oakbrook Terrace, IL 60181