Controlled Substances Questionnaire

Patient Health First

Controlled Substances Questionnaire

(This page is only required if Clinic plans to dispense Controlled Substances)

Operations

Question 1

Ownership

Question 2

Prescriptions

Question 3

Question 4

Question 5

Does the clinic expect to order:

Question 6

Pharmacy

(Required if business is a Pharmacy, otherwise skip to Question 10)

Question 7

Question 8

Has the pharmacist in charge ever:

Question 9

If “Yes” to any in Question 8, please provide further details below (When, Why, etc.)

Patient Type

Question 10

What percentage of your patients come from:

Payments

Question 11

What percentage of your payments come from:

Orders

Question 12

Provide the approximate % of products you expect to order from BRP/DocRx:
And what percentage from other suppliers?