SureScripts

Thank you for your interest in electronic prescribing and streamlining the prescription refill process. We are happy to provide you with the information you need to assist you with establishing a true electronic prescribing connection with pharmacies in your area. Please complete the form below.


First Name:
Last Name:
Position:
Postion(Other):
Practice Name:
Address:
City:
State:
Zip Code:
Telephone:
Fax:  
Email:   
Practice Specialty:
No. of Prescribers in Practice:

Request:

Message:

How would you prefer to receive future communications from SureScripts?

Does your office currently use An Electronic Medical Record (EMR) system?
System Name

An Electronic Prescribing System?
System Name

A Practice Management System?
System Name