emergency order form2009 postbsb uk by HC120912125718

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									FAX:               01494 567401
TELEPHONE: 01494 567400
                                        Emergency Pharmacy Order Form
We understand you are currently experiencing difficulties in obtaining certain products from your wholesalers and you are in urgent need of these
 products. As per the process in these exceptional circumstances , you would like to use the services of Janssen-Cilag Ltd.
                                                                           Wholesaler
                                                                            normally                  Location/
You hereby confirm your order:                                                used                      Depot:
                                                                                 *Wholesaler details must be completed on every order*

   ** PLEASE NOTE UNLESS THE ORDER FORM IS COMPLETED IN FULL YOUR ORDER MAY BE DELAYED**
PHARMACY CONTACT DETAILS:
Janssen-Cilag Acc Number (if known)……………………                               Date…………………………………………….
Premises' Name….………………………………………….                                         Telephone No………………………………..

Branch No (if applicable)……………….………………….                                  Fax No…………………………………………

Address …………...………………………………………….                                          Opening Hours

…………………...…………………………………………….                                                            M          T         W            T            F

…………...…………………………………………………….                                                AM

Postcode………….……………………………………………                                              PM

     Invoice Address (if different from above)                                   Statement Address (if different from above)



COMPULSORY: I confirm I have contacted my wholesaler as mentioned above and I am unable to obtain the products indicated below:-

Signature of Pharmacist:                                                  Name (block capitals) :


    Code      Product         Strength Pack Size Quantity                     Code       Product          Strength        Pack Size Quantity
    90935     RISPERDAL         0.5mg    20 tablets                           196958     TOPAMAX              25mg        60 tablets
    72015     RISPERDAL      20 tablets
                                 1mg                      196340 TOPAMAX     50mg                                         60 tablets
    72029     RISPERDAL      60 tablets
                                 1mg                      196341 TOPAMAX    100mg                                         60 tablets
    72030     RISPERDAL      60 tablets
                                 2mg                      196342 TOPAMAX    200mg                                         60 tablets
    72592     RISPERDAL      60 tablets
                                 3mg                      193186 TOPAMAX     15mg                                         60 Sprinkles
    72593     RISPERDAL      60 tablets
                                 4mg                      193187 TOPAMAX     25mg                                         60 Sprinkles
    87540     RISPERDAL      28 tablets
                                 6mg                      193188 TOPAMAX     50mg                                         60 Sprinkles
    85676     RISPERDAL      100ml Soln
                               1mg/ml
    96562     RISPERDAL      28 Qstab
                                0.5mg                      95931 CONCERTA    18mg                                         30 tablets
    96564     RISPERDAL      28 Qstab
                                 1mg                       95932 CONCERTA    36mg                                         30 tablets
    96566     RISPERDAL      28 Qstab
                                 2mg
   140883     EVRA           1x9 patch                    385098 INVEGA      3mg                                          28 tablets
   140303     CILEST         6x 21tablet                  385099 INVEGA      6mg                                          28 tablets
   197449     CILEST         3x 21tablet                  385100 INVEGA      9mg                                          28 tablets
                                       N.B. SUBJECT TO MAXIMUM ORDER QUANTITIES
NEW ACCOUNT CHECKS (for internal use only):-
* If Dispensing Doctor please ensure you note their Primary Care Trust below:
*Primary Care Trust (for Dispensing Doctors)

Medical Directory

Royal Pharmaceutical Society

Other - Please State:-

Any Special Instructions:-




                                                                                         Janssen-Cilag Ltd
                                                                              50-100 Holmers Farm Way, High Wycombe
                                                                                          Bucks HP12 4DP
                                                                                       Registered in England No 1027904

								
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