BECOME A PRACTICE MEMBER

Name

EMAIL ADDRESS

Practice Name

TITLE

ADDRESS

CITY

STATE/ZIP CODE

PHONE NUMBER

Who is your Practice Administrator?

Practice Administrator Contact

WHO IS YOUR EMR VENDOR?

WHAT GPO DO YOU CURRENTLY USE?

HOW MANY MID LEVEL PROVIDERS (NPs/PAs) ARE AT YOUR PRACTICE?

DO YOU HAVE A DISPENSING PHARMACY? DO YOU HAVE A DISPENSING PHARMACY?YESNO

DO YOU HAVE RADIATION ONCOLOGISTS? DO YOU HAVE RADIATION ONCOLOGISTS?YESNO

DO YOU HAVE A RESEARCH PROGRAM? DO YOU HAVE A RESEARCH PROGRAM?YESNO