QuickMAR Sales Request Form

QuickMAR Sales Request Form

This form is filled out for all facilities looking to add QuickMAR, transfer from one pharmacy to another, or a pharmacy that is converting dispensing software.

Please allow for at least 2 business days for the Sales team to reach out regarding this request.

WE CAN NOT PROCESS ANY REQUESTS WITHOUT THE FACILITY SIGNING TERMS AND CONDITIONS AND VERIFYING THEIR LEGAL NAME AND ALL ADDITIONAL DETAILS REQUEDTED BY THE SALES TEAM. THE 30 DAY CLOCK STARTS ONCE WE RECEIVE THESE ITEMS FROM THE FACILITY.

Please note that all requests should be submitted at least 30 days prior to the requested Go Live date.

Facility Legal Name(s)*

PLEASE ENSURE THE LEGAL NAME OF THE FACILITY ENTERED IS AN EXACT MATCH TO THEIR LISTING ON THE SECRETARY OF STATE’S DATABASE SO THE REQUEST CAN BE PROCESSED

Facility Parent Organization*

Is this facility owned by a Parent Organization? If NO please put N/A

Facility Address(es)*

Facility Primary Contact*

Phone*

E-Mail*

Numbers of Residents in Facility*

Target Go-Live Date*

Is Facility using Quickmar today*

If the facility is using QuickMAR please request a transition project

All QuickMAR Transitions are a move of an entire facility from one pharmacy to a new one. IF you are moving carts within a facility and some of the facility is staying with the current pharmacy then the scope and cost of the project could be increased. This must be clear in the NOTES FOR SALES Team section of this form.

Select or enter value

Type of Implementation Requested*

QuickMAR Implementation Basic Support |

QuickMAR Implementation Enhanced Support |

Transition/Transfer (facility switching pharmacies or merging facilities) |

Conversion (pharmacy switching dispensing software) |

QuickMAR Additional Deployment- Add a location or Med Cart to an existing QuickMAR facility

Select

Who is paying for the Implementation Fees?*

Select

Pharmacy/Fac Code from Dispensing Software

QuickMar Pharmacy ID*

THIS MUST BE FILLED OUT TO ENSURE NO DELAY IN PROCESSING YOUR REQUEST

Pharmacy Name*

Pharmacy Contact*

Pharmacy Address*

Pharmacy Phone*

Pharmacy Email*

Notes*

Please include the pharmacy/facility code if known and any bar code software that will be used.

Pharmacy Authorized Signatory- Email address*

Requester*

Name of person filling out this form

Acknowledgement*

By checking this box I acknowledge the following information:

The sales team will respond to the request within 2 business days.

The request is at least 30 days prior to the requested Go live date.

The request can not be processed until the Facility signs the Terms and Conditions form.

Notes for the Sales Team*

If this is a transition project request- Are all residents and carts transferring to the new pharmacy? If there are no notes for the sales team please put N/A in the box.

Upload a copy of the Facility Signed Terms and Conditions if available

Drag and drop files here or

Send me a copy of my responses

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