Falsified Medicines Directive (FMD)Customer Order Form

Falsified Medicines Directive (FMD) 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)
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For This Branch (£150.00 per Scanner) *
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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

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

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 1 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 2 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 3 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 4 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 5 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 6 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 7 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 8 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 9 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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
*Limited time offer until 1st February 2019*

You will receive a free of charge 2D FMD Compliant Barcode Scanner with every branch that is ordering FMD.
Additional 2D FMD Compliant Barcode Scanners Required For Branch 10 (£150.00 per Scanner)
One free of charge 2D FMD scanner supplied per branch (limited time offer). If you wish to order any more scanners for this branch, please select the additional quantity above.

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

Browse Files

Cancel of

Solution(s) or Services to be provided – Fees collected quarterly by direct debit

FMD software includes:
• Integrated FMD module licence within ProScript Connect
• Remote support
• FMD service requirement updates

Please note: The FMD service can only be pre-ordered if you are using, or have placed an order for ProScript Connect.
Number of Branches ordering the FMD Service (£28.50 per branch per month) *
Please enter the total quantity of site fees required
Monthly Total
Solution(s), Service(s) and/or Goods – Charges

ProScript Connect FMD Service
• Service activation with initial setup
• Technical enablement FMD
• FMD Service software e-learning module
Number of Branches ordering the FMD Service (£595.00 per site one off fee)
Total
Total Quantity of FOC (Free Of Charge) 2D FMD Compliant Barcode Scanners For All Branches
Total Quantity of Additional 2D FMD Compliant Barcode Scanners For All Branches (£150.00 per scanner) excluding free of charge scanners
Please manually update this total if uploading a branch list
Total Cost of Additional Scanners
Total Upfront Cost
VAT
Total incl. VAT

Important service details

Activation of the ProScript Connect FMD service will be carried out remotely on or before 9th February 2019 deadline.

For this service to function, FMD compliant 2D barcode scanners will need to be purchased from EHCP. If you have not already purchased your scanners from EHCP please order above. It is the responsibility of the customer to ensure the correct number of scanners are purchased.

Additional Terms and Conditions

1.	Commencement And Duration
	1.1	The FMD Service is a separate term in respect of certain solution(s), goods, and/or services supplied. The term of the Agreement will come into effect as of the Commencement Date (as defined in the Master Terms) and it shall continue until it (or the relevant Order Form) is terminated by either party giving not less than three (3) months’ notice in writing.
It is the Customer’s responsibility to read and fully familiarise themselves with the Master Terms.

Agreement

By executing this Order Form the Customer accepts that the provision of any Solution(s), Goods, and/or Services here-under 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:

Falsified Medicines Directive (FMD) Service