GP / Medical clinic information form

Name: *

Position/Role: *

Contact Information

Email: *

Phone: *

Fax:

Name of clinic/s and location/s: *

Number of full-time equivalent GPs:

Please estimate the number of HMR referrals your clinic is capable of generating per year:

Does your clinic have experience with HMRs?:

Yes

Any specific problems/issues you had/have with the HMR service?:

Please arrange a Choice QUM representative to brief myself and GPs on your HMR service

We would like to start sending HMR referrals to Choice QUM now and will meet the pharmacist later

Additional comments or queries:

Word verification: * Type the characters you see in this picture.

Type the characters you see in the picture above; if you can't read them, submit the form and a new image will be generated. Not case sensitive.