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Site Information
Please check all of the following that apply to your site. Hospital Independent Community Pharmacy Chain Community Pharmacy Long Term Care Managed Care 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.
Time of Year Preferences
Please rank the time of year during which you would like to meet with a student. Please select your first, second, and third choices. Click here to see approximate dates of these descriptions.
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