BECOME A PRACTICE MEMBER Thank you for your interest in becoming a member of CHOP. To become a member, please complete the form below. Name EMAIL ADDRESS Practice Name TITLE ADDRESS CITY STATE/ZIP CODE PHONE NUMBER WHO IS YOUR EMR VENDOR? WHAT GPO DO YOU CURRENTLY USE? HOW MANY MID LEVEL PROVIDERS (NPs/PAs) ARE AT YOUR PRACTICE? DO YOU HAVE A DISPENSING PHARMACY? DO YOU HAVE A DISPENSING PHARMACY?YESNO DO YOU HAVE RADIATION ONCOLOGISTS? DO YOU HAVE RADIATION ONCOLOGISTS?YESNO DO YOU HAVE A RESEARCH PROGRAM? DO YOU HAVE A RESEARCH PROGRAM?YESNO Number 7 + 10 = Submit FollowFollowFollow