Current pharmacy adding a branch

"*" indicates required fields

Please complete all the required fields below. This Pharmacy Partner Application (“Application”) is not binding on PointClickCare and remains subject to PointClickCare’s review and approval to confirm the accuracy of information in the Application. If there are any discrepancies and/or errors in this Application, a PointClickCare team member will contact you using your contact information indicated below. A typical review cycle of an Application may take up to ten (10) business days to complete. Only upon PointClickCare’s written notification of Application approval to pharmacy will pharmacy listed below will be authorized to begin licensing, interfacing with, and promoting QuickMAR ™ with current and prospective facilities served by the pharmacy in accordance with these Terms & Conditions.

Each pharmacy location must pay a one-time start-up fee. This fee covers the cost of implementing, testing and certifying the interface with pharmacy’s dispensing software and the implementation of one (1) facility location.
PointClickCare will license the QuickMAR Rx ™ software with accompanying interface to the pharmacy, and the QuickMAR ™ software to the facility pursuant to an End-User License Agreement.
PointClickCare may require a facility to accept PointClickCare’s terms and conditions and enter into an agreement with PointClickCare independent of the pharmacy partner.
Pharmacy may request to have facilities added and/or removed from its account. Request will be initiated by submitting the applicable online form as published on the PointClickCare/QuickMAR pharmacy web portal. Fees for professional services, such as implementation and/or transfer fees for such facilities may apply and will be detailed on the applicable Order form.
Pharmacy is responsible for paying all fees for the facilities associated with the pharmacy’s account. Consolidated invoices will be sent directly to the pharmacy each month via e-mail and will itemize the charges for each facility. The cost per facility is based on the number of active residents in the QuickMAR database during the billing period, multiplied by the fee per resident for your pharmacy as published on the PointClickCare/QuickMAR website or as otherwise specified in a Quote/OrderForm.
All Fees will be due within 30 days of the date of PointClickCare’s invoice.
Pharmacy may, in its own discretion, invoice its facility customers the fee for that facility as indicated on the PointClickCare invoice to pharmacy, or at a different rate established by pharmacy. PointClickCare is not a party to any such agreements and/or arrangements between pharmacy and facility.
A facility may opt to purchase other PointClickCare products or services directly from PointClickCare. Such products and services will be invoiced to the facility directly.

Pharmacy Information

Pharmacy Dispensing Software*

Pharmacy Name (This must be the pharmacy legal name that is an exact match to the pharmacy listing on the Secretary of State Business Search. Failure to provide this will delay the processing of this request.)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Pharmacy Time Zone

Pharmacy Phone*

Barcode Packaging*

Additional Interfaces

Pharmacy Contact Name*

Pharmacy Contact Email*

Pharmacy Invoice Contact*

Pharmacy Invoice Email*

Requested QuickMAR Start Date: (Must be at least 4 weeks from this date)*

Terms & Conditions

Please review all terms and conditions.

I have reviewed and agree to all terms and conditions.

I certify that I am an authorized officer or other duly authorized agent of the company, authorized to execute this legally binding agreement.

Pharmacy Authorized Signatory

Facility Information

This Facility Is*

Facility Name*

Facility Legal Business Entity Name*

Facility Address*

Street Address City State / Province / Region ZIP / Postal Code

Facility Time Zone

Facility Phone*

Facility Contact Name*

Facility Contact Email*

Facility Contact Title*

Additional Facility Contacts and Emails

Identify the Type of Facility

Facility Census*

Is Your Facility Part of a Corporation

Yes

Unknown

Facility Corporation Name or QuickMAR ID*

QuickMAR Facility ID*

Facility Name*

Address*

City State / Province / Region

Facility Phone*

Facility Contact Email*

Previous Pharmacy Name*

Notes

This field is for validation purposes and should be left unchanged.

Sales Level	Active Residents	Monthly Fee /Resident
1	1-499	$9.00
2	500-1499	$8.00
3	1500-2999	$7.00
4	3000-4999	$6.00
5	5000	$5.00

Pharmacy Information

Terms & Conditions

Facility Information

I am a QuickMAR Pharmacy Partner.

I was referred by a pharmacy.