CompuRx, Inc.

 

 

In order to join the CompuRx Pharmacist Panel, please complete the following enrollment form.  Please note that all study participants, panel members and data submitted to CompuRx is strictly confidential and will not result in any sales calls.

 

About You/Your Pharmacy

1.  Are you a:

Registered Pharmacist (R.Ph.)/Pharm.D.

Pharmacy Technician

Pharmacy School Student

Other, please specify: 

 

2.  Are you a: 

(Check all that apply)

Hospital-based pharmacist

Retail-based pharmacist

Consultant

Educator/faculty member

Retired

Managed care pharmacist

Long term care pharmacist

Internet pharmacist

Government pharmacist

Other, please specify: 

 

3. For retail-based pharmacists, is your pharmacy a: 

Chain pharmacy

Independent pharmacy

Other, please specify: 

 

4. For retail- and/or hospital-based pharmacists, please provide the following (where applicable):

Hospital Name
Hospital Zip Code
Retail Pharmacy Name
Retail Pharmacy Zip Code

 

 

Contact Information

5.  Please remember that the information you provide will be kept strictly confidential and will only be used by CompuRx to solicit your participation in market research projects.  This information will not be used for advertising purposes or to contact you in any way other than CompuRx sponsored market research projects.

First Name
Last Name
Street Address
City
State Abbrev.
Zip Code
Telephone Number (optional)
Fax Number (optional)
Email Address*

*If you have more than one email address, please provide the preferred contact address.

 

 

Thank-you for taking the time to complete this enrollment form.  Select 'Enroll Now' to send your information to us.

 

              

Read our Confidentiality Agreement