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Customer Info

Name*

Email*

Your Community*

Your Regional Director*

Your Technician

How is your designated account technician doing?*

How is your delivery? Do you get meds when you expect them?*

When was your last consulting service?*

Do you need additional Heartland Pharmacy training (Serenity Engage, Heartland Connect)?*

Equipment

Estimate the number of cards in the med cart*

Number of scripts*

Photos of Equipment

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Max. file size: 1 GB.

Take pictures of any issues/concerns/repairs requested, inventory all equipment provided by Heartland, including med cart serial numbers, colors, key numbers, etc., and laptop/scanners/fax machine quantities.

Celebration of Partnership

Kudos*

names of anyone you think deserves a shoutout

Why do you still use Heartland Pharmacy?*

Review the contract (Equipment, cost-share, consulting, term, etc.):*

Upcoming community events:*

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Thank you for taking the time to fill out our business review.

Customer Info

Your Technician

Equipment

Celebration of Partnership

Corporate Office

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