Refer a Prescriber

About

Thank you for your efforts to encourage local physicians to e-prescribe. Please use this form to request e-prescribing information for a prescriber or practice staff member in your area.
 
Note: We are not able to send this information unless you have first talked with the person you are referring and received their permission to accept follow-up information about electronic prescribing from Surescripts. We have provided a check box for you to acknowledge that this conversation has taken place.

Referring Pharmacy Staff Member Information

Note: All information is required
Pharmacy Name:
If Other/Independant, please specify:
First Name:
Last Name:
I have spoken with this prescriber and they have requested more information from
Surescripts.
Practice Contact
First Name:
Last Name:
Position:
Postion (Other):
Practice Name:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
Email:
Send follow-up
information via:
Practice Specialty:
No. of Prescribers in Practice:
Comments: