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Country
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Select
France (French)
Germany (German)
Italy (Italian)
Spain (Spanish)
United Kingdom (English)
United States (English)
Which best describes your occupation / type of involvement in the Healthcare industry?
This field is mandatory
Select
Dentistry
Diet / Health / Nutrition
Emergency Medical Services
Healthcare IT
Hospital / Medical Office Staff
Managed Care
MD / DO / PA
Nursing (Including Advanced Practice)
Optometry (Not MD)
Pharmacy
Podiatry
Psychology (Not MD)
Therapist
Veterinary Medicine
Other
Which of the following best categorizes your current position in the Dental field?
This field is mandatory
Select
Licensed Dentist
Certified Dental Assistant
Dental Assistant Student
Licensed Dental Hygienist
Dental Hygiene Student
Dental Lab Technician
Office Manager
Receptionist
None of the above
Other
Which of the following best describes your profession?
This field is mandatory
Select
Dietician
Nutritionist
Personal Trainer
Other (please specify)
Please identify your occupation title.
This field is mandatory
Select
EMT- Basic (BLS)
EMT- Intermediate (ALS)
EMT- Paramedic (ALS)
Medical First Responder (BLS)
Paramedic
Which best describes your occupation title?
This field is mandatory
Select
Hospital Administrator
Human Resources
Legal Liasion
Medical Office Manager
Purchasing/Supply Chain Manager
Receptionist
Staffing Manager
Other, please specify
Which of the following best categorizes your current position in the Managed Care industry?
This field is mandatory
Select
Administrator
Assistant / Associate Medical Director
Assistant / Associate Pharmacy Director
Executive
Formulary Manager
Medical Director
Other (please specify)
Pharmacy Director
Staff Pharmacist of a MCO
Which of the following best categorizes your current degree attainment status?
This field is mandatory
Select
Medical Doctor
Doctor of Osteopathy
Physician Assistant
Resident Physician
Which of the following best describes your nursing certification level?
This field is mandatory
Select
Registered Nurse
LPN / LVN: Licensed Practical Nurse
Nurse Practitioner
Nursing Aid
Other (please specify)
None of the above
What type of Nurse Practitioner are you?
This field is mandatory
Select
Family Nurse Practitioner
Adult-Gerontology Acute Care Nurse Practitioner
Adult-Gerontology Primary Care Practitioner
Neonatal Nurse Practitioner
Pediatric Nurse Practitioner (Acute or Primary Care)
Psychiatric Mental Health Nurse Practitioner
Women’s Health Nurse Practitioner
Which of the following specialty areas are you most often affiliated with in your current role?
This field is mandatory
Select
Addiction Medicine
Allergy and Immunology
Anesthesiology
Bariatric Surgery
Cardiology
Critical Care-ICU
Dermatology
Emergency Medicine
Endocrinology, Diabetes & Metabolism
Family Practice-General Practice
Gastroenterology
Geriatrics
Hematology
Hemodialysis
Hepatology
Hospice
Infection Control
Infectious Disease
Infusion
Internal Medicine
Labor and Delivery
Medical Genetics
Medical/Surgical
Neonatal-NICU-PICU
Nephrology
Neurology
Obstetrics & Gynecology
Oncology-Cancer
Operating Room
Ophthalmology
Orthopedics
Otolaryngology/ENT
Pain Medicine
Pediatrics
Perinatal
Physical Medicine & Rehabilitation
Plastic-Cosmetic Surgery
Post-Anesthesia- PACU
Preventative Medicine
Psychiatry
Pulmonology
Radiology
Rheumatology
Telemetry
Urology
Vascular Surgery
Wound Care
Not Applicable
Other, please specify
Do you hold any of the following positions or titles?
This field is mandatory
Case Manager
Certified Diabetes Educator
Charge Nurse
Clinical Nurse Specialist
Community / Public Health Nurse
Head Nurse / Nurse Supervisor
Hospital Department Manager
Lactation Consultant
Nursing Administration
Nursing Professional Development (Nurse Educator)
None of the above
Which of the following best categorizes your current degree attainment status?
This field is mandatory
Select
Licensed Pharmacist
Pharmacy Student
Licensed Pharmacy Assistant
Pharmacy Assistant Student
Pharmacy Technician
Intern
Other (please specify)
Which of the following best describes your profession?
This field is mandatory
Optometrist
Optician
Other (please specify)
Which of the following best describes your profession?
This field is mandatory
Select
Doctor of Podiatric Medicine
Podiatric Technician
Podiatric Nurse
Other (please specify)
Which of the following best describes your professional status/ involvement type?
This field is mandatory
Select
Abuse Hotlines
Addiction Medicine Specialist
Adolescent Medicine Specialist
Child Psychologist
Clinical Psychologist
Community Support
General Psychologist
Social Worker
Other: Please specify
Which of the following best describes your profession?
This field is mandatory
Select
Occupational Therapist
Physical Therapist
Rehabilitation Therapist
Respiratory Therapist
Other (please specify)
Which of the following best categorizes your current degree attainment status?
This field is mandatory
Select
Office management / Reception in a Veterinary facility
Veterinarian
Veterinary Technician
None of the above
Please identify your areas of concentration. (select as many as apply)
This field is mandatory
Cosmetic Dentistry
Dental Public Health
Endodontics
General Dentistry (AEGD)
Gerodontics
Oral and Maxilloafacial Pain
Oral and Maxilloafacial Pathology
Oral and Maxilloafacial Radiology
Oral and Maxilloafacial Surgery
Oral Implantology
Specialty Licensure date - Orthodontics and Dentofacial Orthopedics
Pediatric Dentistry
Periodontics
Prosthodontics
Temporomandibular Joint Disorder
What role do you play in the purchasing of Dental Supplies?
This field is mandatory
Select
I make the final decision
I make the final decision in consultation with others
I provide recommendations only
I play no role
What type of patients do you see in your practice?
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Select
Adult only
Pediatric only
Both Adult and Pediatric
Choose the title  that most closely resembles your current position
This field is mandatory
Select
Chief Clinical Officer
Chief Compliance Officer
Chief Executive Officer-President
Chief Financial Officer
Chief Information Officer
Chief Medical Information Officer
Chief Medical Officer
Chief Nursing Officer/Vice President Nursing or Patient Care Services
Chief of Medical Staff
Chief Operating Officer
Chief Quality Officer
Chief Technology Officer
Vice President, Clinical Cancer Center and Cardiovascular Health-service line leader
Vice President, Controller
Vice President, Finance
Vice President, Healthcare Data and Analytics
Vice President, Health Information Management
Vice President, Human Resources
Vice President, Medical Affairs
Vice President, Operations
Vice President,Patient Financial Services
Vice President, Revenue Cycle
Vice President, Risk Management
Other
Which Best describes the hospital type at which you spend the majority of your professional time?
This field is mandatory
Select
General/Community Hospital
Academic/Teaching Hospital
Federally Funded/VA
Other
What is the patient capacity of the hospital at which you have primary privileges?
This field is mandatory
Less than 100 beds
101-199 Beds
200-299 bed
300-399 beds
400+ Beds
How would you classify your primary practice setting?
This field is mandatory
Ambulatory Care Center
General Hospital
Group Practice
Long Term Care/Nursing Home
Private Practice
Teaching Hospital
Other
Are you a voting P & T (Pharmacy and Therapeutic) Committee Member?
This field is mandatory
Select
Yes
No
What role do you play in formulary composition decisions?
This field is mandatory
Select
I make the final decision.
I make the final decision in consultation with others.
I provide recommendations only.
I play no role.
How would you describe your organization?
This field is mandatory
Select
Health Plans
Pharmacy Benefits Management Company (PBM)
Both health Plans and PBM
Integrated Delivery System
Other (please specify)
Which of the following best describes where you are currently employed?
This field is mandatory
Select
Formulary group for government / VA hospitals.
Formulary group for a single hospital.
Formulary group for a network of hospitals.
Localized MCO
Localized Private Insurance Formulary
National MCO
National Private Insurance Formulary
Regional MCO
Regional Private Insurance Formulary
Other (please specify)
How many lives are currently covered by your organization?
This field is mandatory
Select
Less than 100K
100 - 299K
300 - 499K
500K - 1 million
More than 1 million
What is your primary specialty? (Please select only the field for which you have completed a minimum of a residency)
This field is mandatory
Select
Addiction Medicine
Allergy & Immunology
Anesthesiology
Cardiology
Interventional Cardiology
Critical Care Medicine
Dermatology
Endocrinology, Diabetes & Metabolism
Emergency Medicine
Family Practice/General Practice
Gastroenterology
Genetics
Geriatrics
Hematology
Hepatology
Hospitalist
Infectious Disease
Internal Medicine
Nephrology
Neurology
Obstetrics & Gynecology
Oncology
Ophthalmology
Orthopedics/Orthopedic Surgery
Otolaryngology/ENT
Pain Medicine
Pathology
Pediatrics
Physical Medicine & Rehabilitation
Plastic/Cosmetic Surgery
Preventive Medicine
Psychiatry
Pulmonology
Radiology
Interventional Radiology
Rheumatology
Surgery
Urology
Are you the Pharmacy owner?
This field is mandatory
Select
Yes
No
Are you the person in charge of your Pharmacy?
This field is mandatory
Select
Yes
No
Please select the category that best describes your type of pharmacy practice.
This field is mandatory
Select
Clinical Pharmacy
Commercial Managed Care Organization / Healthcare Plan
Compounding Pharmacy
Consultant Pharmacy
Home Health Agency
Hospital Pharmacy
Retail - Independent
Infusion
Long-Term Care - Rehabilitation
Nuclear Pharmacy
Oncology Pharmacy
Pharmacy Benefit Management Company
Retail - Chain
Pharmacy Management Service Provider
Psychiatric Facility
Specialty Pharmacy
Veterinary Pharmacy
Other, please specify
Which of the following Pharmacy Chains are you associated with?
This field is mandatory
Select
Cardinal Health Inc
Costco
CVS Corporation
Domonick's Finer Foods
Fred Meyer Pharmacy Division
Fred's Inc
Giant Eagle Pharmacy
Giant Food Stores LLC
H E B Drug Stores
Hy-Vee Inc
Kaiser Permanente
K-Mart
Kroger Company
Medicine Shoppe International
Meijer Pharmacies
Publix Pharmacies
Rite Aid Corporation
Safeway
Sears Holdings Corporation
Shopko Stores Inc
Shoprite Supermarkets Inc
Smith's Food & Drug Centers Inc
Stop & Shop Supermarket Co
Supervalu Pharmacies
Target Corp
Walgreens Corporate Office
Other
Walmart Stores Inc
Winn-Dixie Pharmacies
Which of these Allergy & Immunology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Allergy
Allergy & Immunology/Diagnostic Lab
Allergy & Immunology
Immunology
Pediatric Allergy
Pediatric Immunology
Other
None of the Above
Which of these Anesthesiology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Critical Care Anesthetics
Hospice and Palliative Medicine
Pain Management Anesthetics
None of the Above
Which of these Cardiology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
IM - Cardiac Electrophysiology
Interventional Cardiology
Nuclear Cardiology
None of the Above
Which of these Dermatology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Cosmetic Dermatology
Dermatopathology
Pediatric Dermatology
None of the above
Which of these Emergency Medicine sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Critical Care
Emergency Medical Toxicology
Emergency/Sports Medicine
Hospitalist
Pediatric Emergency Medicine-EM
Undersea and Hyperbaric Medicine-EM
Urgent Care Medicine
None of the above
Which of these Endocrinology, Diabetes & Metabolism sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Diabetes
Reproductive Endocrinology
None of the above
Which of these Family Practice / General Practice sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Adolescent Medicine (Family Practice)
Geriatrics
Sleep Medicine
None of the above
Which of these Gastroenterology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Hepatology
None of the above
Which of these Genetics sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Clinical Biochemical Genetics
Clinical Cytogenetics
Clinical Genetics
Clinical Molecular Genetics
Medical Genetics
Metabolic Genetics
Molecular Genetic Pathology
Pediatric Genetics
None of the above
Which of these Geriatrics sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Family Practice-Geriatric Med
Geriatric Psychiatry
Hospitalist
Internal Medicine - Geriatrics
Long-term Care Geriatrics
Other
None of the above
Which of these Hematology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Hematology/Oncology
Pediatric Hematology
None of the above
Which of these Infectious Diseases sub-specialties are you involved with? Please select all that apply.
This field is mandatory
HIV/AIDs Specialist
None of the above
Which of these Internal Medicine sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Adolescent Medicine
Cardiology
Critical Care Medicine
Endocrinology, Diabetes & Metabolism
Gastroenterology
Hematology
Hepatology
HIV/AIDS Specialist
Hospitalist
IM - Diagnostic Lab Immunology
Infectious Diseases
Internal Medicine - Pediatrics
Internal Medicine - Sports Med
Medical Oncology
Nephrology
Nutrition
Pulmonary Critical Care Med.
Pulmonary Disease
Rheumatology
Sleep Medicine
Vascular Medicine
None of the above
Which of these Neurology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Brain Injury Medicine
Child Neurology
Clinical Neurophysiology
Epilepsy
Neurodevelopmental Disabilities/Movement Disorders
Neurological Surgery
Neuromuscular Medicine
Pain Medicine
Pediatric Neurological Surgery
Sleep Medicine
Vascular Neurology
None of the above
Which of these Obstetrics & Gynecology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Gynecology
Gynecologic Oncology
Maternal & Fetal Medicine
Reproductive Endocrinology
Surgery
None of the above
What type of oncology do you specialize in? Please select all that apply.
This field is mandatory
Clinical Oncology
Gynecological Oncology
Hematology/Oncology
Medical Oncology
Orthopedic Musculo Oncology
Pediatric Hematology Oncology
Radiation Oncology
Surgical Oncology
None of the above
Which of these Ophthalmology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Glaucoma Specialist
Pediatric Opthalmology
Retinal Specialists
None of the above
What type of orthopedics/Orthopedic Surgery do you specialize in? Please select all that apply.
This field is mandatory
Adult Reconstructive Surgery
Hand Surgery
Orthopedics (Foot & ankle)
Orthopedic Pediatric Surgery
Orthopedic Sports Medicine
Orthopedic Surgery
Orthopedic Surgery of the Spine
Orthopedic Surgery - Trauma
None of the above
Which of these Otolaryngology / ENT sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Otology - Neurotology
Pediatric Otolaryngology
Plastic Surgery - Head & Neck
Sleep Medicine
None of the above
Which of these Pathology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Anatomic Pathology
Anatomic/Clinical
Blood Banking
Chemical
Clinical Pathology
Cytopathology
Dermatopathology
Forensic Pathology
Hematological Pathology
Medical Microbiology
Molecular Genetic Pathology
Neuropathology
Pediatric Pathology
Selective Pathology
None of the above
Which of these Pediatrics sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Adolescent Medicine
Allergy
Anesthesiology
Cardiology
Critical Care
Developmental - Behavioral
Diag Lab Immunology
Emergency Medicine
Endocrinology
ENT
Gastroenterology
Hematology
Hospitalist
Infectious Diseases
Internal Medicine
Medical Toxicology
Nephrology
Neuromuscular Medicine
Neonatal-Perinatal Medicine
Neurodevelopmental Disabilities
Neurology
Pain Medicine
Pediatrics- General
Psychiatry
Pulmonology
Rehab Medicine
Rheumatology
Sports Medicine
None of the Above
Which of these Physical Medicine & Rehabilitation sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Pediatric Rehabilitation Medicine
Spinal Cord Injury
Sports Medicine
None of the Above
Which of these Plastic / Cosmetic Surgery sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Bariatric Surgery
Craniofacial Surgery
Facial Plastic Surgery
Laproscopic Surgery
Reconstructive Surgery
None of the Above
Which of these Preventive Medicine sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Aerospace Medicine
General Preventive Medicine
Occupational Medicine
Preventive Medical Toxicology
Public Health/General Prevent Med
Undersea Medicine
None of the above
Which of these Pulmonology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Hospitalist
Pulmonary Critical Care Med.
Pulmonary Critical Care Medicine/Intensivist
Sleep Medicine
None of the above
Which of these Radiology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Abdominal Radiology
Cardiothoracic Radiology
Diagnostic Radiology
Musculoskeletal Radiology
Neuroradiology
Nuclear Radiology
Pediatric Radiology
Radiological Physics
Vascular/ Interventional Radiology
None of the above
Which of these Rheumatology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Pediatric Rheumatology
None of the above
What type of surgery do you specialize in? Please select all that apply.
This field is mandatory
Abdominal Surgery
Bariatric Surgery
Cardiothoracic Surgery
Cardiovascular Surgery
Colon & Rectal Surgery
Cosmetic Surgery
Critical Care Surgery
Dermatologic Surgery
Endovascular Surgical Neuroradiology
General Surgery
Gynecological Surgery
Hand Surgery
Head & Neck Surgery
Laproscopic Surgery
Neurological Surgery
Orthopedic Surgery
Oral And Maxillofacial Surgery
Plastic Surgery
Pediatric Cardiothoracic Surgery
Pediatric Surgery
Proctolgy
Reconstructive Surgery
Thoracic Surgery
Transplant Surgery
Traumatic Surgery
Vascular Surgery
Other
None of the above
Which of these Urology sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Female Pelvic Medicine and Reconstructive Surgery
Pediatric Urology
Proctology
Urological Surgery
None of the above
Please select your practice setting
This field is mandatory
Ambulatory Surgery Center
College or School Health
Dialysis Facility
Hemophilia Treatment Center
Home Health Agency
Hospital or Clinic
Long Term Care / Rehabilitation
Mental Health / Psychiatric Facility
Office/Private Practice
School of Nursing-College
Other, please specify
Which of these Psychiatry sub-specialties are you involved with? Please select all that apply.
This field is mandatory
Addiction Psychiatry
Child Psychiatry
Epilepsy
Forensic Psychiatry
Neuromuscular Medicine
Neuropsychiatry
Pain Medicine (Psychiatry)
Pediatric Psychiatry
Psychoanalysis
Psychosomatic Medicine
Sleep Medicine
None of the above
First Name
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Last Name
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Gender
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Male
Female
Date of Birth
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January
February
March
April
May
June
July
August
September
October
November
December
Username
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Email
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Confirm Email
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Password
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Confirm Password
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Passwords do not match
Zip Code
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City
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Street Address
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Additional address information (optional)
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Mobile phone number(optional)
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State Licence Number
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State of License
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AK
CA
DE
IL
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KS
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MB
MD
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MI
MN
MO
MS
MT
NB
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NV
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PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
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YT
AB
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