First Name

Last Name

Job Title

Email

Cell Phone

Postal Code

Health System Name

Total number of facilities (including acute, non-acute, EVS, etc)

Are you currently sourcing PDI products from multiple distributors and/or channels? YesNo

Primary Distributor Cardinal Concordance Henry Schein McKesson Medline NDC/MedPlus Owens and Minor Other

Other Primary Distributor

Is there a formal Value Analysis committee process required for formulary changes? YesNo

If yes for Value Analysis, please provide your contact's name, title and email address:

Is your item master managed centrally? (select all that apply) ERPLawsonWorkdayOracle

Is it your goal to standardize your surface disinfectant wipe into one formulary, one price, one contract across your Health System? YesNo

Please provide any additional information that would be helpful for PDI:

Yes, I want to receive periodic emails from PDI regarding news, events, and product information Yes

Comments