Genoa Healthcare Pharmacy Questionnaire

If you would like to find out if a clinic pharmacy is an option for your organization, please complete the questionnaire below and we will respond via email or telephone within five working days.

If your organization has more than one outpatient clinic, feel free to complete as many of the questionnaires as needed, one per site.

This is a long form. Please continue to scroll down and complete the entire form. Press Send Questionnaire at the end of the form to complete the online questionnaire process.

Organization Contact Information

Organization Name*

Contact*

Contact Email*

Website

Phone*

Street Address*

City*

State*

Zip Code*

* indicates required field

Organization and Facility Information

Facility's Annual Budget

Total Patients Serviced

Number of Prescribers

Organization's Staff Size

Number of Patients under a Medication Management Program

Number of Outpatient Clinics within the organization

Number of Patients using Clozapine

Do your facilities offer medication management services?

Do your facilities maintain a medication room?

How many patients serviced by your clinics utilize the manufacturer Patient Assistance Programs (PAP)?

Do your facilities receive sample medications?

Does your organization manage any residential facilities?

If so, how many beds?

Does your organization manage an Evaluation and Treatment Center or rehab programs?

If so, what is the patient capacity of these programs?

Send your questionnaire