Independent Pharmacy - On-line Questionnaire or pdf Form

If you do not receive an e-mail message within 30 seconds after pressing the “Submit” button, please check your Junk e-mail folder. If no message was received, you can complete the questionnaire using the pdf version of the questionnaire attached below.

Please click here to open or save a pdf version of this questionnaire:
Note:To view this file you will need Adobe Acrobat installed on your computer. If you do not have Adobe Acrobat, please click on the link below to download a free version: If you still have trouble opening or viewing this file, please call Customer Support at 901-373-9314.