Enterprise Client Intake, Compliance & Onboarding Form

SECTION 1: LEGAL, CORPORATE & OWNERSHIP INFORMATION

Legal Entity Name (Registered):

DBA / Trade Name(s):

Parent Organization / Holding Company (if applicable):

Subsidiaries, Affiliates, or Related Entities:

Organization Type:

HospitalHealth System / IDNLong-Term Care NetworkAssisted LivingOutpatient ClinicHome Healthcare AgencyGovernment / Public SectorNonprofit
Other:

Tax ID / EIN:

NPI Number(s):

CMS Certification Number(s):

Primary Corporate Address:

Street:

City:

State:

Zip:

Country:

Corporate Website:

SECTION 2: EXECUTIVE LEADERSHIP & AUTHORIZED DECISION-MAKERS

Chief Executive Officer (Name / Email / Phone):

Chief Financial Officer (Name / Email / Phone):

Chief Medical Officer / Clinical Director:

Supply Chain / Procurement Executive:

Authorized Contract Signatory (if different):

SECTION 3: PROCUREMENT, BILLING & FINANCIAL OPERATIONS

Procurement Model:

CentralizedDecentralizedHybrid

Purchase Order (PO) Required?

YesNo

Billing Entity Name (if different from Legal Entity):

Accounts Payable Contact (Name / Email / Phone):

Average Monthly Medical Supply Spend:

Estimated Annual Medical Supply Budget:

Current GPO Membership(s):

SECTION 4: FACILITY, CLINICAL & OPERATIONAL PROFILE

Total Number of Facilities / Locations:

Facility Types:

Acute Care HospitalLong-Term Care / SNFRehabilitationOutpatient / AmbulatoryHome HealthSpecialty Care
Other:

Total Licensed Beds (if applicable):

Average Daily Census:

Annual Patient Encounters / Visits:

Clinical Specialties Supported:

Total Staff Size:

Clinical:

Non-Clinical:

SECTION 5: MEDICAL SUPPLY DEMAND & PRODUCT CATEGORY DETAIL

Primary Medical Supply Categories Required:

PPEDiagnostic SuppliesMedical ConsumablesDurable Medical Equipment (DME)Infection ControlFacility & Environmental SuppliesEmergency / Surge SuppliesSpecialty or Physician-Preferred Products
Other:

Critical or Life-Sustaining Products:

Physician-Preferred or Brand-Specific Requirements:

Estimated Monthly Product Volume:

Forecasted Growth or Volume Changes (Next 12–24 Months):

Seasonal, Emergency, or Surge Demand Considerations:

SECTION 6: ORDERING, LOGISTICS & DISTRIBUTION REQUIREMENTS

Preferred Ordering Method:

Online PortalEDIEmailPhoneOther

Standard Delivery Frequency:

WeeklyBi-WeeklyMonthlyAs Needed

Delivery Locations & Dock Access Notes:

Receiving Hours (by location if applicable):

Cold Chain or Special Handling Requirements:

Emergency / Disaster Response Delivery Expectations:

SECTION 7: INVENTORY MANAGEMENT & STORAGE

Current Inventory Management Method:

ManualERP-BasedThird-Party ManagedHybrid

Average Days of Inventory on Hand:

Current Inventory Challenges (Stockouts, Overstock, Waste):

Interest in Inventory Optimization / VMI Programs:

YesNoInterested in Learning More

SECTION 8: COMPLIANCE, REGULATORY & QUALITY REQUIREMENTS

Applicable Regulatory Bodies:

FDACMSOSHAState Health AuthoritiesFederal / Government StandardsOther

Required Certifications or Documentation:

Audit or Vendor Documentation Requirements:

Recall Notification & Escalation Protocols:

SECTION 9: TECHNOLOGY, DATA & SYSTEMS INTEGRATION

ERP / Procurement Systems Used:

EDI, API, or System Integration Requirements:

Data Reporting, Analytics & KPI Expectations:

Cybersecurity, Vendor Risk, or IT Compliance Requirements:

SECTION 10: RISK MANAGEMENT & BUSINESS CONTINUITY

Emergency Preparedness / Pandemic Planning Needs:

Critical Item Prioritization Criteria:

Business Continuity & Supply Assurance Expectations:

SECTION 11: STRATEGIC PARTNERSHIP OBJECTIVES

Primary Objectives in Selecting Robb Health Corporation:

Key Challenges with Current or Previous Suppliers:

Cost Optimization, Stability, or Growth Targets:

KPIs Used to Measure Supplier Performance:

Desired Length and Scope of Partnership:

SECTION 12: CONTRACTING, LEGAL & PAYMENT TERMS

Preferred Contract Type:

Master Services AgreementSpot PurchasingIDIQGovernment ContractOther

Preferred Contract Term Length:

Requested Payment Terms:

Net 30Net 45Net 60
Other:

Insurance, Indemnification, or Legal Requirements:

SECTION 13: PRIOR SUPPLIER EXPERIENCE & REFERENCES

Current or Previous Primary Suppliers:

Reason for Change or Evaluation (if applicable):

Professional References (Optional):

SECTION 14: ADDITIONAL DISCLOSURES & SPECIAL REQUIREMENTS

Special Handling, Labeling, Packaging, or Sustainability Requirements:

ESG, Diversity, or Community Impact Requirements:

Additional Notes or Considerations:

SECTION 15: CERTIFICATION, AUTHORIZATION & SIGNATURE

I certify that the information provided is accurate and complete to the best of my knowledge and authorize Robb Health Corporation to use this information.

Authorized Signatory Name:

Title:

Signature (Type Full Name):

Date: