First Name*
 
 
Last Name*
 
 
 
Email*
 
 
Phone*
 
 
 
Facility Name*
 
 
Zip Code*
 
 
 
Medline Account #
 
 
 
 
Medline Sales Representative (if known)
 
 
 
 
What is your preferred contact method?
 
Phone
Email
Other
 
 
 
 
 

What is the ownership breakdown of this facility?

 
 
Hospital (%)
 
 
Physician Ownership (%)
 
 
 
Management Group (%)
 
 
Other (%)
 
 
 
Management group partner:
 
 
Other ownership partner:
 
 
 
 
 
How many procedure rooms do you have?*
 
 
 
 
What is your case volume per month, per room in your procedural room(s)?
 
 
 
 
How many operating rooms do you have?*
 
 
 
 
What is your case volume per month, per room in your operating room(s)?
 
 
 
 
What types of procedures are performed at your center?*
 
Dental
Dermatology
Ear, Nose and Throat (Otolaryngology)
Endoscopy/Gastroenterology
Ophthalmology
Obstetrics and Gynecology
Orthopedics - Foot and Ankle
Orthopedics - Hand
Orthopedics - Knee
Orthopedics - Shoulder
Pain
Plastics
Spine
Urology
 
 
 
Other procedures performed:
 
 
 
 
 
 

Purchasing information

 
 
Which GPO do you belong to?*
 
HPG
Intalere
MedAssets
Premier
Vizient
None
 
 
 
Who is your current distributor?*
 
Cardinal Health
Henry Schein
McKesson
Medline Industries, Inc.
Owens
Other
 
 
 
Are you aware of your current distribution rate?*
 
Yes
No
 
 
 
If so, what is your current distribution rate?
 
 
 
 
Most of the time, how do you place your orders?*
 
Customer Service
E-mail
EDI
Fax
Sales Rep
Website
 
 
 
What is your preferred method to place your orders?*
 
Customer Service
E-mail
EDI
Fax
Sales Rep
Website
 
 
 
Do you have a dedicated customer service rep?*
 
Yes
No
 
 
 
What is your process to reconcile and pay invoices?*
 
 
 
 
Do you have dedicated staff to maintain manufacturing contracts?*
 
Yes
No
 
 
 
When prices change for your supplies, is this always communicated to you?*
 
Yes
No
 
 
 
What is your biggest supply spend?*
 
 
 
 
Will you be working on any large (e.g., remodel, move or new center) or capital projects (e.g., new equipment) in the next 12-24 months?*
 
Yes
No
 
 
 
Please elaborate if yes
 
 
 
 
 
 

Delivery/Stocking Information

 
 
What day/days do you receive deliveries? Please select all that apply.*
 
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
 
 
Can your facility accommodate palletized delivery?*
 
Yes
No
 
 
 
How are orders checked in?*
 
Manual
Scanner
 
 
 
Who is your source for sutures and endomechanical devices? *
 
Current Distributor
Suture Express
N/A
Other
 
 
 
What is currently your largest pharmaceutical spend? *
 
 
 
 
Who is your current pharmaceutical source? *
 
 
 
 
To offer you the best solution for supplies, can you provide an item file with manufacturer name, item numbers and item usage in an Excel format?*
 
Yes
No
 
 
 
 
 

Additional Comment Box

 
 
Please provide any additional insight you would like us to consider or questions you would like us to address in devising your customized solution. *