commQUM form for Community Pharmacies

Name: *

Position/Role: *

Contact Information

Email: *

Phone: *

Fax:

Individual pharmacy or group: *

Individual pharmacy

Group

Pharmacy Location/s: *

Please provide a general description/background of your pharmacy/s:

(e.g. competitive environment; retail setting; customer demographic; size/sales; # of DAA patients; # of local GPs/clinics; # of pharmacists and employees; strengths/weakeness and opportunities and threats etc...)

Do you supply medications to any ACFs and how many facilities:

Do you have any existing QUM/RMMR contracts and for how many BEDs:

Approximate number of HMRs conducted through your pharmacy/group over the past 12 months:

Please describe any existing ‘in-shop’ professional services you provide:

What are the key benefits you hope to obtain from enlisting our commQUM package:

(e.g. differentiate your pharmacy from local discounters; gear your pharmacy to capitalise on emerging funding for professional services; build customer loyalty; increase PBS revenues; DAA growth etc...)

Do you have any specific concerns about the potential for our service to meet your needs? Any barriers to subscribing to commQUM:

Additional comments or queries:

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