OPA MTM Committee Project: Ohio’s MTM Story Submission Form
Intent: Communicate with patients, media, legislators, physicians, and other potential supporters the prevalence and value of pharmacist MTM services throughout Ohio.
Sign in to Google to save your progress. Learn more
Site Name: *
Site Address (Address, City, State, Zip) *
Site Contact Phone Number: *
Site Hours of Operation: *
Services Provided: *
(MTM, diabetes teaching, smoking cessation, etc.)
Summary of Program Offered: *
(short paragraph/narrative, 3-4 sentences, target audience 7th grade reading level)
Example Intervention: *
(medication related problem identified/corrected by pharmacist)
Quote: *
(patient, physician, or other testimonial/feedback)
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy