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</HEAD>
<BODY MARGINWIDTH="0" MARGINHEIGHT="0" topmargin="0" BGCOLOR="#ffffff"
onload="CSScriptInit();">
<FORM METHOD=POST ACTION="/scripts/dmd/dmdhosp.taf?Function=Mail">

<P>

<TABLE WIDTH="730" BORDER="0" CELLSPACING="0" CELLPADDING="0">
  <TR>
    <TD WIDTH="50%" VALIGN="TOP">
      <P><CENTER><IMG SRC="/enrollment_images/doctor3.jpg"  
      ALIGN="BOTTOM" BORDER="0" NATURALSIZEFLAG="3"><BR>
      </CENTER></P>

      <P><CENTER><B><FONT SIZE="-2" FACE="Verdana">Personnel<BR>
      Contact Information</FONT></B></CENTER></P>

      <P><CENTER><FONT SIZE="-2" FACE="Arial">Delta Marketing Dynamics<BR>
      5760 Commons Park Drive<BR>
      East Syracuse, NY 13057<BR>
      phone: (315)492-2905<BR>
      fax: (315) 492-1740<BR>
      <A HREF="http://www.deltamarketingdynamics.com/">deltamarketingdynamics.com</A></FONT><BR>
      </CENTER></P>

      <P><CENTER><B><FONT SIZE="-2" FACE="Verdana">William R. Little</FONT></B><FONT

       SIZE="-2" FACE="Arial"><BR>
      President<BR>
      email: <A HREF="mailto:wrlittle@deltamktgdyn.com">wrlittle@deltamktgdyn.com</A></FONT></CENTER></P>

      <P><CENTER><B><FONT SIZE="-2" FACE="Verdana">Linda G. Crolick</FONT></B><FONT

       SIZE="-2" FACE="Arial"><BR>
      Manager of Syndicated Studies<BR>
      email: <A HREF="mailto:lcrolick@deltamktgdyn.com">lcrolick@deltamktgdyn.com</A></FONT></CENTER></P>

      <P><CENTER><B><FONT SIZE="-2" FACE="Verdana">Patty Trainor</FONT></B><FONT

       SIZE="-2" FACE="Arial"><BR>
      Senior Director of Primary Research<BR>
      email: <A HREF="mailto:ptrainor@deltamktgdyn.com">ptrainor@deltamktgdyn.com</A></FONT></CENTER></P>


      <P><CENTER><B><FONT SIZE="-2" FACE="Verdana">Webmaster</FONT></B><FONT

       SIZE="-2" FACE="Arial"><BR>
      email: <A HREF="mailto:webmaster@deltamktgdyn.com">webmaster@deltamktgdyn.com</A></FONT></CENTER>
    </TD>
    <TD WIDTH="50%" VALIGN="TOP"><TABLE WIDTH="445" BORDER="0" CELLSPACING="0"
      CELLPADDING="0">
        <TR HEIGHT="98">
          <TD WIDTH="445" VALIGN="TOP" HEIGHT="98"><MAP NAME="contcthdMap2">
    <AREA SHAPE="rect" COORDS="341,3,383,15" HREF="http://www.dmdsurveys.com/survey_splash.html">
</MAP><IMG SRC="/contact_images/contcthd.gif" WIDTH="445" HEIGHT="98"
            ALIGN="BOTTOM" BORDER="0" NATURALSIZEFLAG="3" USEMAP="#contcthdMap2"
            ISMAP></TD> 
        </TR>
        <TR HEIGHT="62">
          <TD WIDTH="445" VALIGN="TOP" HEIGHT="62"><TABLE BORDER="0" CELLPADDING="0"
            CELLSPACING="0" HEIGHT="62">
              <TR>
                <TD WIDTH="41"><IMG SRC="/about_images/navtable1.jpg" WIDTH="41"
                  HEIGHT="62" NATURALSIZEFLAG="3" ALIGN="BOTTOM"></TD> 
                <TD><TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0">
                    <TR>
                      <TD><csobj w="122" h="20" t="Button" ht="/navbut2_images/navbut10o.gif" csover="B6D2F59876" csout="B6D2F59877"><A

                        HREF="http://www.dmdsurveys.com/aboutsurveys.html" onmouseover="CSAction(new Array(/*CMP*/'B6D2F59876'));return CSIShow(/*CMP*/'navbut1',1)"
                        onmouseout="CSAction(new Array(/*CMP*/'B6D2F59877'));return CSIShow(/*CMP*/'navbut1',0)"
                        onclick="return CSButtonReturn()"><IMG SRC="/navbut2_images/navbut1.gif"
                        WIDTH="122" HEIGHT="20" NAME="navbut1" BORDER="0" NATURALSIZEFLAG="3"
                        ALIGN="BOTTOM"></A></csobj></TD> 
                      <TD><csobj w="123" h="20" t="Button" csover="B6D2F59878" csout="B6D2F59879"><A

                        Href="http://www.dmdsurveys.com/security_privacy.html" onmouseover="CSAction(new Array(/*CMP*/'B6D2F59878'));return CSIShow(/*CMP*/'navbut2',1)"
                        onmouseout="CSAction(new Array(/*CMP*/'B6D2F59879'));return CSIShow(/*CMP*/'navbut2',0)"
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                        WIDTH="123" HEIGHT="20" NAME="navbut2" BORDER="0" NATURALSIZEFLAG="3"
                        ALIGN="BOTTOM"></A></csobj></TD> 
                      <TD><csobj w="123" h="20" t="Button" csover="B6D2F59880" csout="B6D2F59881"><A

                        Href="http://www.dmdsurveys.com/panel_enroll.html" onmouseover="CSAction(new Array(/*CMP*/'B6D2F59880'));return CSIShow(/*CMP*/'navbut3',1)"
                        onmouseout="CSAction(new Array(/*CMP*/'B6D2F59881'));return CSIShow(/*CMP*/'navbut3',0)"
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                        WIDTH="123" HEIGHT="20" NAME="navbut3" BORDER="0" NATURALSIZEFLAG="3"
                        ALIGN="BOTTOM"></A></csobj></TD> 
                    </TR>
                    <TR>
                      <TD><IMG SRC="/navbut2_images/navbut4.gif" WIDTH="122" HEIGHT="21"
                        NATURALSIZEFLAG="3" ALIGN="BOTTOM"></TD> 
                      <TD><csobj w="123" h="21" t="Button" csover="B6D2F59882" csout="B6D2F59883"><A

                        HREF="http://www.dmdsurveys.com/dmd_interact_site/interact_splash.html" onmouseover="CSAction(new Array(/*CMP*/'B6D2F59882'));return CSIShow(/*CMP*/'navbut5',1)"
                        onmouseout="CSAction(new Array(/*CMP*/'B6D2F59883'));return CSIShow(/*CMP*/'navbut5',0)"
                        onclick="return CSButtonReturn()"><IMG SRC="/navbut2_images/navbut5.gif"
                        WIDTH="123" HEIGHT="21" NAME="navbut5" BORDER="0" NATURALSIZEFLAG="3"
                        ALIGN="BOTTOM"></A></csobj></TD> 
                      <TD><csobj w="123" h="21" t="Button" csover="B6D2F59884" csout="B6D2F59885"><A

                        Href="https://www.dmdsurveys.com/respondent_login.html" onmouseover="CSAction(new Array(/*CMP*/'B6D2F59884'));return CSIShow(/*CMP*/'navbut6',1)"
                        onmouseout="CSAction(new Array(/*CMP*/'B6D2F59885'));return CSIShow(/*CMP*/'navbut6',0)"
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                        WIDTH="123" HEIGHT="21" NAME="navbut6" BORDER="0" NATURALSIZEFLAG="3"
                        ALIGN="BOTTOM"></A></csobj></TD> 
                    </TR>
                    <TR>
                      <TD><IMG SRC="/navbut2_images/navbut7.gif" WIDTH="122" HEIGHT="21"
                        NATURALSIZEFLAG="3" ALIGN="BOTTOM"></TD> 
                      <TD><IMG SRC="/navbut2_images/navbut8.gif" WIDTH="123" HEIGHT="21"
                        NATURALSIZEFLAG="3" ALIGN="BOTTOM"></TD> 
                      <TD><csobj w="123" h="21" t="Button" csover="B6D2F59886" csout="B6D2F59887"><A

                        Href="https://www.dmdsurveys.com/scripts/dmd/DMDContact.taf" onmouseover="CSAction(new Array(/*CMP*/'B6D2F59886'));return CSIShow(/*CMP*/'navbut9',1)"
                        onmouseout="CSAction(new Array(/*CMP*/'B6D2F59887'));return CSIShow(/*CMP*/'navbut9',0)"
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                        WIDTH="123" HEIGHT="21" NAME="navbut9" BORDER="0" NATURALSIZEFLAG="3"
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                    </TR>
                  </TABLE></TD>
                <TD WIDTH="36"><IMG SRC="/about_images/navtable3.jpg" WIDTH="36"
                  HEIGHT="62" NATURALSIZEFLAG="3" ALIGN="BOTTOM"></TD> 
              </TR>
            </TABLE></TD>
        </TR>
        <TR HEIGHT="284">
          <TD WIDTH="445" VALIGN="TOP" HEIGHT="284">
            <br><b><font face="Arial" size="3"><i>HOSPITAL PANEL REGISTRATION FORM<p></i></font></b>
			<FONT SIZE="-1" FACE="Arial">Please provide as much information as
			  possible.&nbsp; As stated in our<br><a href="http://www.dmdsurveys.com/security_privacy.html">Privacy Policy</a>, DMD will never
			  provide respondent-identifiable information<br>in any report, nor
			  will we release your personal information to<br>outside parties unless you give
			  us express permission to do so.<br></font><BR>
            </FONT><TABLE WIDTH="409" BORDER="0" CELLSPACING="0" CELLPADDING="0">
              <TR>
                <TD WIDTH="321" BGCOLOR="#cccccc" ALIGN="CENTER">
                  <P ALIGN=LEFT><TABLE WIDTH="209" BORDER="0" CELLSPACING="1" 
                  CELLPADDING="4">

 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Title
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

  <select size="1" name="Title">
    <option>Mr.</option>
    <option>Ms.</option>
    <option>Miss</option>
    <option>Mrs.</option>
    <option>Dr.</option>
  </select>
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

First Name
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="First_Name" size="15">
  						</FONT></B></TD> 
                    </TR>


	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Last Name
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Last_Name" size="20">
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Please enter your HOSPITAL name and address
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Hospital Name<br>
<input type="text" name="Hosp_name" size="30"><br>
Address1<br>
<input type="text" name="Hosp_address1" size="30"><br>
Dept. <br>
<input type="text" name="Hosp_dept" size="15"><br>
Address2<br>
<input type="text" name="Hosp_address2" size="30"><br>
Mail Drop #<br>
<input type="text" name="Mail_drop" size="15"><br>
City<br>
<input type="text" name="Hosp_city" size="20"><br>
State<br>
<select size="1" name="Hosp_state">
    <option>AL</option>
    <option>AR</option>
    <option>AZ</option>
    <option>CA</option>
    <option>CO</option>
    <option>CT</option>
    <option>DC</option>
    <option>DE</option>
    <option>FL</option>
    <option>GA</option>
    <option>HI</option>
    <option>IA</option>
    <option>ID</option>
    <option>IL</option>
    <option>IN</option>
    <option>KS</option>
    <option>KY</option>
    <option>LA</option>
    <option>ME</option>
    <option>MD</option>
    <option>MA</option>
    <option>MI</option>
    <option>MN</option>
    <option>MS</option>
    <option>MO</option>
    <option>MT</option>
    <option>NE</option>
    <option>NV</option>
    <option>NH</option>
    <option>NJ</option>
    <option>NM</option>
    <option>NY</option>
    <option>NC</option>
    <option>ND</option>
    <option>OH</option>
    <option>OK</option>
    <option>OR</option>
    <option>PA</option>
    <option>RI</option>
    <option>SC</option>
    <option>SD</option>
    <option>TN</option>
    <option>TX</option>
    <option>UT</option>
    <option>VT</option>
    <option>VA</option>
    <option>WA</option>
    <option>WV</option>
    <option>WI</option>
    <option>WY</option>
  </select><br>
Zip Code<br>
<input type="text" name="Hosp_zip" size="10"><br>
Telephone #<br>
<input type="text" name="Hosp_phone" size="15"><br>
Fax #<br>
<input type="text" name="Hosp_fax" size="15">
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Please complete if you wish to receive surveys at your home address:
	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Address<br>
<input type="text" name="Home_address" size="30"><br>
City <br>
<input type="text" name="Home_City" size="20"><br>
State <br>
<select size="1" name="Home_state">
    <option>AL</option>
    <option>AR</option>
    <option>AZ</option>
    <option>CA</option>
    <option>CO</option>
    <option>CT</option>
    <option>DC</option>
    <option>DE</option>
    <option>FL</option>
    <option>GA</option>
    <option>HI</option>
    <option>IA</option>
    <option>ID</option>
    <option>IL</option>
    <option>IN</option>
    <option>KS</option>
    <option>KY</option>
    <option>LA</option>
    <option>MA</option>
    <option>MD</option>
    <option>ME</option>
    <option>MI</option>
    <option>MN</option>
    <option>MO</option>
    <option>MS</option>
    <option>MT</option>
    <option>NC</option>
    <option>ND</option>
    <option>NE</option>
    <option>NH</option>
    <option>NJ</option>
    <option>NM</option>
    <option>NV</option>
    <option>NY</option>
    <option>OH</option>
    <option>OK</option>
    <option>OR</option>
    <option>PA</option>
    <option>RI</option>
    <option>SC</option>
    <option>SD</option>
    <option>TN</option>
    <option>TX</option>
    <option>UT</option>
    <option>VA</option>
    <option>VT</option>
    <option>WA</option>
    <option>WI</option>
    <option>WV</option>
    <option>WY</option>
  </select> <br>
Zip Code<br>
<input type="text" name="Home_Zip" size="10">

 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Please check how you would prefer to have honorariums paid:

 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="radio" value="Store" name="Pay_to"> Pay honorariums to hospital above<br>
<input type="radio" name="Pay_to" value="Pharmacist" checked> Pay honorariums directly to me
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Do you have access to the world wide web?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="checkbox" name="Web_access" value="Yes" style="position: relative"> Check if &quot;Yes&quot;
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

May we contact you by email to present survey and honorarium opportunities?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="checkbox" name="Contact_by_email" value="Yes"> Check if &quot;Yes&quot;
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Please enter your email address:
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Email_address" size="30">
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Is this your pharmacy email address or your home email address?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="radio" name="Email_location" value="Pharmacy"> Pharmacy email address<br>
<input type="radio" name="Email_location" value="Home"> Home email address
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Are you a registered pharmacist?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="checkbox" name="Registered_pharm" value="Yes"> Check if &quot;Yes&quot;
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

What year did you begin practicing as a pharmacist?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Year_began" size="10">
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

What year did you begin with the pharmacy listed above?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Began_at_pharm" size="10">
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Number of staffed beds at your hospital:
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Staffed_beds" size="10"> (Please do not guess if you do not know.)
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Number of full-time pharmacists at your hospital:
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Number_pharm" size="10">
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Please check the type(s) of data/information you can provide:
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="checkbox" name="Inv_use_purch" value="Can Provide"> Inventory, Usage, Dispensing and Purchasing Information<br>
<input type="checkbox" name="Acquisition_patient_cost" value="Can provide"> Net Acquisition/Invoice Cost<br>
<input type="checkbox" name="Diagnosis_data" value="Can provide"> Patient diagnosis data: # patients treated by diagnosis, drugs used, dosing information, etc.<br>
<input type="checkbox" name="Drug_distribution" value="Can provide"> Drug distribution volume (# vials, amps, etc.) to various departments from central pharmacy<br>
<input type="checkbox" name="Other_dept_info" value="Can provide"> Drug related information from other hospital departments (ex. Card Cath Lab, ER, etc.)<br>
<input type="checkbox" name="Opinions_attitudes" value="Can provide"> Opinions/Attitudes/Perceptions<br>
<input type="checkbox" name="Formulary_status" value="Can provide"> Formulary Status
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Estimated total DAILY pharmacy Rx order volume:
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Daily_rx_volume" size="10"> # Rx orders/day

 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

Were you referred to our site by another pharmacist?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="checkbox" name="Referred" value="Yes"> Check if &quot;Yes&quot;
 						</FONT></B></TD> 
                    </TR>


 	<TR HEIGHT="30">
		<TD WIDTH="171" ALIGN="RIGHT" BGCOLOR="#e6e5e7" HEIGHT="30">&nbsp;<B>
		<FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

If yes, what is the ID number of the pharmacist who referred you to our site?
 	</FONT></B>
	</TD> 
	<TD WIDTH="325" BGCOLOR="#e6e5e7" HEIGHT="30"><B><FONT COLOR="#000000" SIZE="-2" FACE="Verdana">

<input type="text" name="Referring_pharm_ID" size="10">
 						</FONT></B></TD> 
                    </TR>


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