Pharma-Care, Inc. - Facility Profile Sheet

So that Pharma-Care's Consultant Pharmacist can quickly get started on your facility please fill in the below information.
 This form may also be used to send updated information. You may also download a PDF version of the information form and Fax Back to the Operations Department at Pharma-Care.

LINK TO PDF FORM

QUICK START FACILITY FORM

NEW / UPDATE
Correct Spelling of
Facility Name		 Correct Spelling of
Floors or Unit Names
Address: Address Cont'd 1
City: Zipcode State 2
Main Telephone No: Main Fax No: 3
Facility Capacity 4
Administrator Ass't Administrator 5
Director of Nursing Ass't Director of Nursing 6
Medical Director Pharmacy
Provider 		7
Period of Last Visit Date of last D.O.H. Survey 8
Other Key Personnel Title
Average Census LTC:  SA OTHER/TYPE /
Send Monthly Reports to who's attention:

How to Send:

 FAX  or POSTAL or EMAIL

Comments or Special Request

Quarterly P&T

What Months do the hold their quarterly meetings?: QTR1:   QTR2:   QTR3:   QTR4:

Health Care Support Systems
Copyright © 2008 Pharma-Care, Inc.. All rights reserved.
Revised: December 01, 2009