Genoa Healthcare Qualification Form

Genoa Healthcare Pharmacy Questionnaire
If you would like to find out if an on-site pharmacy is an option for your organization, please complete the questionnaire below. We will respond via email or telephone within five working days. If your organization has more than one outpatient clinic, feel free to complete as many of the questionnaires as needed, one per site.

Please make sure to fill out the entire form, continue to scroll down until completion. Press Submit at the end of the form to complete the online questionnaire process. We look forward to hearing from you and are excited you have chosen to explore your options with Genoa!

Organization Contact Information

Organization Name*

Contact*

Contact Email*

Website

Phone*

Street Address*

City*

State*

Zip Code*

* indicates required field

Organization and Facility Information

Facility's Annual Budget

Total Clients Serviced

Number of Prescribers

Organization's Staff Size

Number of clients under a Medication Management Program

Number of Outpatient Clinics within the organization

Number of Clients using Clozapine

Do your facilities offer medication management services?

Do your facilities maintain a medication room?

How many clients serviced by your clinics utilize the manufacturer Patient Assistance Programs (PAP)?

Do your facilities receive sample medications?

Does your organization manage any residential facilities?

If so, how many beds?

Does your organization manage an Evaluation and Treatment Center or rehab programs?

If so, what is the client capacity of these programs?

Send your questionnaire