RMMR/QUM information form for ACFs

Name: *

Position/Role: *

Contact Information

Email: *

Phone: *

Fax:

Individual ACF or group?: *

Individual ACF

Group

Number of approved aged care BEDS: *

ACF name/s and location/s :

Are you interested in Choice QUMs: *

QUM & RMMR services

QUM only

RMMR only

Who is your existing supply pharmacy :

What are the key benefits you see in our service:

(e.g. no supply affiliation, CPD education, etc...)

Do you have any concerns/barriers that may prevent you from utilising our service:

(e.g. existing RMMR/QUM contracts; supply pharmacy arrangement etc...)

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.