CompuRx, Inc.

 

In order to join the CompuRx Physician 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 Practice

1.  What is your primary specialty? 

1a.  If applicable, what is your secondary specialty? 

 

2.  What is your practice status?

Office-based only

Hospital-based only

Both office- and hospital-based

Educator/faculty member

Retired

Other, please specify: 

 

3. Number of years in practice: 

 

4. Year of birth: 

 

5.  Approximate number of patients you personally see/treat in an average month: 

 

6.  Do you have affiliations with any of the following?

AIDS Clinic

Cardiac Clinic

Dialysis Center

Home Health Care Agency

Hospital, Community

Hospital, Teaching/Major Medical Research Center

Long Term Care Facility

Oncology Clinic/Center

Psychiatric Hospital/Facility

Public Health Clinic

SurgiCenter, Freestanding

SurgiCenter, Hospital Affiliated

VA/DOD Facility

 

 

Contact Information

7.  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
Relative to you office/practice:
Street Address
City
State
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