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Coronavirus Info 731-554-9872 fax@wtnpc.com 24 Nolan Cove, Jackson, TN, 38305Mon-Fri: 8 AM-5 PM (Closed 1-2 PM)

West TN Pharmaceutical

A service oriented long term care pharmacy that helps you stay connected
in the loop of communications so that patient care is the focused target!

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Home
Services
Links & Forms
Resources
About Us
Contact Us

Links & Forms

Forms and Surveys

Customer Survey

Customer Survey Form

Were you greeted when you arrived to the pharmacy? *YesNo

Were our employees friendly? *YesNo

Were our employees attentive to your needs? *YesNo

Were our employees knowledgeable? *YesNo

Did you receive everything that you came for? *YesNo

To help us serve you better, please rate your service experience.

Please use the following scale for rating your experience:

1 = extremely not satisfied/not likely
2 = not satisfied/not likely
3 = fairly satisfied/likely
4 = satisfied/likely
5 = extremely satisfied/likely

How satisfied are you with the service you received? *12345

How satisfied are you with our company overall? *12345

How likely are you to use our services again? *12345

How likely are you to recommend our services and our company to others? *12345

What did you like or not like about our services and our company?

What can we do to improve in the future?

Optional: If you would like to leave your contact information below so that we may contact you about your comments, you can do so here.

Name

Phone

HTML

Thank you for taking the time to complete the survey! We appreciate your business.

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Please do not fill in this field.

New Agency/Facility Inquiry

New Agency/Facility Inquiry

We work with agencies and facilities to fulfull the pharmaceutical needs of patients. Please fill out the form below and someone will get back to you.

Agency/Facility Name *

Name *

Email Address *

Phone Number *

Your Message *

Anti-Spam

Please do not fill in this field.

Update Patient/Client Info

Update Patient/Client Info

If you need to update patient information, please fill out the form below.

Facility/Agency Name *

Client's Name *

New Drug/Other Allergies

New Street Address

New Address Line 2

New City

New State

New ZIP Code

New Phone Number

Roommate(s)

New Nurse and Coordinator Names

New Home Manager Name

New Home Manager Phone Number

New PCP and/or Psych provider

Anti-Spam

Please do not fill in this field.

New Patient Form

New Patient Form

Notice of Privacy Practices: Click here to read, download, or print.

I have received the pharmacy’s Notice of Privacy PracticesBy checking this box, I, (client’s name) or (conservator’s name if client unable to sign) or (staff’s name if client unable to sign) acknowledge that I have received a copy of the pharmacy’s Notice of Privacy Practices.

Facility/Agency Name *

Client Name *

Patient's Gender *

Date of Birth *

Patient's Social Security Number *Enter a nine digit SSN with no dashes

Drug Allergies/Any Other Allergies *

Patient's Street Address *

Patient's Address Line 2

Patient's City *

Patient's State *

Patient's ZIP Code *

Nurse and Coordinator Names

Roommate(s)

Home Manager

Home Manager's Phone Number

PCP Provider

Psych Provider

Name of Agency/Conserator/Responsible Party for services *

Phone Number of Responsible Party *

Responsible Party Street Address *

Responsible Party Address Line 2

Responsible Party City *

Responsible Party State *

Responsible Party ZIP Code *

AGREEMENT: The undersigned agrees that West TN Pharmaceutical Care is hereby authorized to provide pharmacy services as ordered by the long term care facility shown above for the enrolled patient/client, and that the pharmacy is to bill those charges on a monthly basis to the undersigned responsible party. The responsible party further agrees to make payments promptly to the providing pharmacy at the address indicated for all charges billed. The responsible party is also to inform the pharmacy of any changes in billing address or if patient/client has transferred out of the agency.

Digital Signature *By typing my full name here, I confirm that this digital signature is the legal equivalent to my print signature.

Anti-Spam

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Medication Refill Order

Medication Refill Order

Facility/Agency Name *

Client's Name *

Staff Name *

Staff Phone # *

RX#

Name of Med *

Pick Up By Date *

Anti-Spam

Please do not fill in this field.

Additional Links/Documents

Helpful Links
HIPAA Privacy Practices
Patient’s Narcotic Record
Medication Record – Front
Medication Record – Back
Update Info Sheet
Checklist for Pharmacy and Facility
Acknowledgement of Receipt
Pharmacy Service Agreement
Credit Card Authorization Form
ACH Bank Authorization Form
SMS Terms of Service
SMS Privacy Policy

Patient care first.
Quality service, always.

Contact Us Today!

Home
Services
Links & Forms
Resources
About Us
Contact Us

Home
Services
Links & Forms
Resources
About Us
Contact Us

Main office location

24 Nolan Cove, Jackson, TN, 38305

Call us for any need

Phone: 731-554-9872
Fax: 731-554-9874

Office business hours

Mon – Fri: 8 AM – 5 PM, closed 1-2 PM
Sat, Sun: Closed

Mail

fax@wtnpc.com

We at West TN Pharmaceutical Care are dedicated to providing our customers with services that are customized to meet their needs. We specialize in serving the needs of the intellectually disabled and other recipients in supported and assisted living facilities. To learn more, contact us today!

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