Name of Pharmacy: *
Pharmacy Manager's Name: *
Address: *
City/Province:*
Postal code:*
Telephone:*
Cell:
Fax:
Email Address:
Pharmacy System Used: *
Average RX per day:*
Business Hours: *
Mon-Fri:
Saturday:
Sunday:
Other:
Will there be a technician working with relief pharmacist: *	Yes No
Is the Pharmacy full technician order entry ( ie: the relief Pharmacist does not need to have full knowledge of the Pharmacy software) :*	Yes No
Is this a specialty Pharmacy? *	Yes No
If YES:	Methadone Internet /Mail Order Compounding
....	Nursing Home
Other:
Comments: