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RoundtableRx Medication Donation Questionnaire
This form will ask you for detailed information about the medications and/or medical supplies you wish to donate. The form should take around 5 minutes to complete.
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* Indicates required question
Email
*
Your email
Phone Number
*
Your answer
How did you hear about RoundtableRx? Select all that apply.
*
Internet search (e.g. Google, Bing, etc.)
Healthcare professional (e.g. doctor, nurse, pharmacist, etc.)
News article
A friend or family member
Other:
Required
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