Constant Connect Customer Order Form

Constant Connect Service

Customer Order Form
Pharmacy Name *
Company Name (Name of Legal Entity) *
RXID *
Name *

First Name Last Name
Email *
example@example.com
Customer’s Registered office *
Pharmacy Address (if different to registered office)
Phone Number *

- Area Code Phone Number
Group Name
(if applicable)

Add Additional branches within your group on one form?

You may add additional branches below by selecting "Click to add additional branch" (limited to a max. of 10 branches) or alternatively you may upload a branch list by selecting "Click to add branch list".
Premises to which the Solution(s), Services or Goods are to be provided

The agreement will also apply to all branches added below (and shall form part of the same agreement)

Click to add additional branch
Branch 1 Name
Branch 1 RXID
Branch 1 Address
Branch 1 Phone Number

- Area Code Phone Number
Branch 1 Manager Name

First Name Last Name
Branch 1 Email
example@example.com

Click to add additional branch
Branch 2 Name
Branch 2 RXID
Branch 2 Address
Branch 2 Phone Number

- Area Code Phone Number
Branch 2 Manager Name

First Name Last Name
Branch 2 Email
example@example.com

Click to add additional branch
Branch 3 Name
Branch 3 RXID
Branch 3 Address
Branch 3 Phone Number

- Area Code Phone Number
Branch 3 Manager Name

First Name Last Name
Branch 3 Email
example@example.com

Click to add additional branch
Branch 4 Name
Branch 4 RXID
Branch 4 Address
Branch 4 Phone Number

- Area Code Phone Number
Branch 4 Manager Name

First Name Last Name
Branch 4 Email
example@example.com

Click to add additional branch
Branch 5 Name
Branch 5 RXID
Branch 5 Address
Branch 5 Phone Number

- Area Code Phone Number
Branch 5 Manager Name

First Name Last Name
Branch 5 Email
example@example.com

Click to add additional branch
Branch 6 Name
Branch 6 RXID
Branch 6 Address
Branch 6 Phone Number

- Area Code Phone Number
Branch 6 Manager Name

First Name Last Name
Branch 6 Email
example@example.com

Click to add additional branch
Branch 7 Name
Branch 7 RXID
Branch 7 Address
Branch 7 Phone Number

- Area Code Phone Number
Branch 7 Manager Name

First Name Last Name
Branch 7 Email
example@example.com

Click to add additional branch
Branch 8 Name
Branch 8 RXID
Branch 8 Address
Branch 8 Phone Number

- Area Code Phone Number
Branch 8 Manager Name

First Name Last Name
Branch 8 Email
example@example.com

Click to add additional branch
Branch 9 Name
Branch 9 RXID
Branch 9 Address
Branch 9 Phone Number

- Area Code Phone Number
Branch 9 Manager Name

First Name Last Name
Branch 9 Email
example@example.com

Click to add additional branch
Branch 10 Name
Branch 10 RXID
Branch 10 Address
Branch 10 Phone Number

- Area Code Phone Number
Branch 10 Manager Name

First Name Last Name
Branch 10 Email
example@example.com

Click to add branch list
Please download and complete this Branch Upload Spreadsheet. Then upload the spreadsheet below.
Upload Spreadsheet

Browse Files

Cancel of

(If there are no additional branches, please click Next)

Constant Connect service – Fees collected quarterly by direct debit

Constant Connect Service Charge per month (the “Service Charge”)*

*Area and signal strength dependent
Number of Branches ordering the Constant Connect Service (£35.00) per branch per month) *
Please enter the total quantity of site fees required
Total monthly cost for all services listed above
I confirm that 2 (two) spare power sockets are available adjacent to the N3 router****. Please tick box to confirm *

Agreement

By executing this Order Form the Customer accepts that the provision of any Solution(s), Goods, and/or Services hereunder by EHCP shall be subject to the terms of the existing Agreement which is in place between the parties (and which is subject to EHCP’s Master Terms and Conditions (the “Master Terms”) (a copy of which is available by following this link http://www.securepharm.co.uk/T&C/Rx Master Services Agreement.pdf)) and this Order Form is incorporated by reference into the Agreement.
Name *

First Name Last Name
Date *

- Day - Month Year
Date
*
Should be Empty: