Form

First name*

Last name*

Email*

Phone number*

Company name*

Pharmacy NPI(s)*

Organization Tax ID*

What pharmacy dispensing software do you use at your store(s)?

Pharmacy Attestation
In order to succeed in the More Than a Script Program, pharmacies will need to have the following:

Appropriate staffing and personnel
Program champion at the site
Appropriate time and space for the champion and other personnel to learn about the initiative, discuss with patients, and conduct patient encounters
Have an established process to define roles and responsibilities for personnel involved
Completion of clinical and technical training + submission of a test encounter in DocStation

Please note, if you don't have these items completed yet, this does not exclude you from the program. Additional resources will be shared prior to More Than a Script launch to ensure success.

By submitting this form, I hereby acknowledge that my pharmacy currently meets the outlined standards or will seek support and resources necessary to achieve such standards prior to ensure success. Please confirm that you have or will have these items completed prior to the More Than a Script launch.