P4235.49-V1

Order Request

There are times when product supply is restricted. Restrictions can be put in place by healthcare organisations at different times for many reasons. Please use this form to request additional products from PHOENIX Healthcare Distribution Limited.
1.	Please supply the following information.
Full PHOENIX Account Number:		
Pharmacy Name:		
Pharmacy Postcode:		
2.	Declaration.
I declare that this request is correct and complete, that refrigerated or controlled items are non-returnable. This request is to fulfill a patient prescription in the UK. I understand that if this request is non compliant it will not be actioned and could lead to appropriate action being taken.
3.	Request details.
PHOENIX Product Code:		
Product Name:		
Quantity Required:		
4.	Signed by person responsible for this request and that I am authorised to do so.
Full Name: (block capitals)		
Job Title:		
Date:		

All sections to be fully completed or we will be unable to complete this request.

Our friendly customer service team will reply to your email confirming your request or if they require additional information from you.

Please email this fully completed request form to: customerservice@phoenixmedical.co.uk

PHOENIX Healthcare Distribution Limited.
Registered Office:
Rivington Road, Whitehouse Industrial Estate, Preston Brook, Runcorn, Cheshire, WA7 3DJ Tel: +44 (0)1928 750 500 Fax: +44 (0)1928 750 750
www.phoenixmedical.co.uk
Co Registration No 00129370 VAT No 109898228