form intake

1 · Organization information

The basics about your organization.

Organization legal name *

Please enter your organization's legal name.

Organization type *

Please select your organization type.

Please specify organization type

Website URL *

Please enter your website address.

Primary practice address — street *

Please enter your street address.

City *

Please enter your city.

State *

Please select your state.

ZIP *

Please enter your ZIP code.

Number of locations *

Please select the number of locations.

State(s) of operation *

No states selected

Please select at least one state of operation.

EHR system currently used

Please specify EHR system

2 · Primary contact

Who should we speak with?

First name *

Please enter your first name.

Last name *

Please enter your last name.

Title / role *

Please enter your title or role.

Direct phone number *

Please enter a valid phone number.

Email address *

Please enter a valid email address.

Best time to reach you

Preferred contact method

4 · Current situation

Where things stand today.

Are you currently using any medication adherence tools or programs? *

Please select an option.

Please describe briefly

What is your biggest challenge with patient medication adherence right now? *

Please describe your biggest adherence challenge.

What prompted you to look into It's Pill Time today?

How did you hear about It's Pill Time?

Which platform?

5 · Timeline & budget

So we can match the right next step.

How soon are you looking to implement a solution? *

Please select a timeline.

Do you have budget allocated for a patient adherence solution?

6 · Legal & compliance readiness

A couple of questions your compliance team will thank us for.

Does your organization require a signed BAA (Business Associate Agreement) before sharing patient information with vendors?

Who in your organization would need to approve a vendor contract?

Please confirm you are authorized to inquire on behalf of your organization.

7 · Consent

This consent is required so we can respond to your inquiry.

Please agree to the Privacy Policy to continue.

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Thank you!

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