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Survey

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Please provide the following contact information: Asterisk (*) Denotes Required Field

    * Your Name:

    * Your Title:

    * Hospital/Affiliation:

    Address:

    * City:

    * State:

    * Zip Code:

    * Work Phone:

    * Fax:

    * Your Email:

    # of Beds, if Hospital:

    # of Patients Served, if Home Infusion:

    GPO Affiliation:

    Contact Person for Purchasing:

    If you were able to purchase products in the SmartPak® system containing quantities of products greater than the currently available pharmacy bulk packages, which of the following items would you use?

    Please rate the products as follows:
    1. Definitely Would Use
    2. Would Likely Use
    3. May Use
    4. Probably Would Not Use
    5. Definitely Would Not Use

    Product

    Rating

    2. Approximately how many grams or million units of the following products does your institution use?

    Please fill in the column that is easiest for you to estimate:

    PRODUCT

    SMALLEST QTY

    LARGEST QTY

    Thank you for your time and assistance! Please take a moment to select your free gift.

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