Your Guide to Selecting E-Prescribing Technology

PART 1: Your Practice's Current Use of and Interest in Technology
1. How many prescribers are in your practice?
  
2. Does your practice use an online system for lab orders and results?


 
3. Is your practice interested in acquiring:


 

PART 2: Current Prescribing Volume
4. How many prescription refill requests does your practice receive per day via phone and fax?
Est. #   
5. How much time (in hours) is spent per day managing prescription refill requests?
NOTE: Please use decimals to indicate time increments that are less than an hour or for partial hours (e.g., 30 min = .5; 1 hour, 30 min = 1.5).
Each Prescriber:    Office Staff (Collectively):   
 

PART 3: Your Information
First Name:  
Last Name:  
Your Title/Role:  
If other, please specify:  
Practice Name:  
Address:  
 
City:  
State:  
Zip:  
Fax:  
Phone:  
Email: