What is your title?
First Name
Last Name (We cannot pay you without a last name):
Practice or Hospital Name:
Practice or Hospital Address:
Practice or Hospital City:
Practice or Hospital State:
Practice or Hospital Zipcode:
Practice or Hospital Phone Number:
Practice or Hospital Fax:
What is your Primary Specialty?
If Other, please specify:
What is your Sub-Specialty?
Please check how you would prefer to have honorariums paid:	Pay to the Practice or Hospital Pay to directly to me
Home Address (If you do not want your checks to go to the practice or hospital):
Home City:
Home State:
Home Zipcode:
Contact Phone (NOT Home Phone)(If you do not want us to call the pharmacy number):
Do you have access to the world wide web?	Yes No
May we contact you by email to present survey and honorarium opportunities?	Yes No
Email Address:
Are you a registered pharmacist?	Yes No
What year did you begin as a physician?
What year did you begin with the practice or hospital above?
What type of practice are you involved in?	Single Group
If Group, how many physicians are in the practice?
How many patients do you treat annually?
What type of setting is your practice located in?	Rural Suburban Urban