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Site Information
Please check all of the following that apply to your practice: Hospital Independent Community Pharmacy Chain Community Pharmacy Long Term Care Managed Care Home Health Administrative Academia Other (please describe)
Please provide a brief description of your pharmacy and/or any unique offerings at your site:
Example: XYZ Pharmacy is an independent pharmacy serving a community of 5000 patients. We package medications in unit dose form for our patients. We also fill med boxes for residents at a local assisted living center. Please include the name of the pharmacy/institution.
Position Information
Please check all that apply to your position description category: Practitioner Administrator Faculty Researcher Industry Representative Liaison Other (please describe)
Time of Year Preferences
New in 2009: Matches will be made one time for the year in order to promote frequent meetings and avoid scheduling conflicts.
Availability
Would you be willing to meet with more than one student at a time? Yes No
Please list the maximum number of students you would be willing to mentor within a given period of time. (For example, no more than 2 students per time frame, or, no more than 4 students per year.)
Please forward any questions to: Mentor Program Coordinator UW School of Pharmacy, Mailbox # 14 777 Highland Ave Madison, WI 53705 Email