PTCommunity.com - Registration

PTcommunity.com - Member Registration

All required fields appear in RED.

If you have a registration code from a mailing, enter it here:

Title:

First Name:

Last Name:

Primary E-Mail Address:

Secondary E-Mail Address:

Organization:

Address:

City:

State/Province:

Zip/Postal Code:

Country:

Office Phone:

Office Fax:

Username

(up to 12 characters):

(No spaces please!)

Password

(up to 12 characters):

Confirm Password:

City of Birth:

(this information will speed retrieval of our username or password should you forget either in the future)

Would you like to turn on auto-login for future visits at PTcommunity.com?

Yes No

(The computer you're at will remember your username and password for future visits.)

Are you involved in formulary decision-making?

Yes No

Do you serve on a P&T Committee

Yes No

If yes, and the committee serves an organization other than your place of employment,
enter the organization name:

Education Level:

1st: 2nd: 3rd:

Which of the following best describes you?

(You must complete at least one of the fields at right.)

Physician Specialty

Pharmacist Specialty

Executive/Administrative

Other Specialty

If other, please specify

Primary Workplace:

Hospital

Managed Care Organization: HMO PPO POS

Government (federal, state, local, military)

Academia

Physician Office

PBM

Pharmaceutical Manufacturer

Consulting

Other

How many covered lives in your organization?

covered lives

If you work in a hospital, how many staffed beds are there?

staffed beds

How did you hear about PTcommunity.com?

What topics would you like to see addressed by PTcommunity.com?

Check here if you would like to receive our e-newsletter?

Yes No

Newletter type:

Plain Text HTML Format

Privacy Statement