Fax 01392 256289

Office 01392 252740

Please send all correspondence, surveys & payment to:

Application Form

3 ways to pay…

CFEP UK Surveys P O Box 51 Exeter EX4 4WT

Complete this form and post to us with payment (cheques should be made payable to ‘CFEP UK Surveys’) Call us on 01392 252740 with your credit or debit card details Apply and pay online at


Pharmacy manager or contact person: (Dr/Mr/Mrs/Ms/Miss) NPA member? Y N OF


Pharmacy name: Address: Direct contact tel no: Monthly script volume (items): E-mail address: Name of host PCT/LPC etc:

Our ref:

For more information or guidance on any aspect of the Community Pharmacy Patient Questionnaire, please contact Karen on

01392 286921
or e-mail

We may contact you from time to time to keep you up to date with products and services that we feel may be of interest to you. If you would not like us to retain your e-mail address for this purpose, please tick here We may wish to pass your details onto the NPA in order to update their records. If you would not like us to do so, please tick here

Price Guide
Average monthly prescription volume (items) Questionnaires needed Questionnaires supplied Cost (excluding VAT)

I would like to receive my survey pack on [date]:
NB: Allow 10 working days for delivery

Price calculator
Survey price £


0 - 2000 2001-4000 4001-6000 6001-8000 8001+

50 75 100 125 150

95 140 190 235 285

£120 £174 £180 £198 £219

Please choose one of the following report formats: Bound hard copy (included in survey price) Electronic copy (included in survey price) (an additional £15 + VAT) Both

Optional extras
Both report formats A2 PVC results poster Subtotal £ 15

Full colour customised results poster
Share your results with patients

Choose from: A4 paper (inc. in survey price) A2 PVC (£40 + VAT)

£ 40 £ £ £

This price includes complete survey pack, feedback report, A4 customised results poster, and supporting materials. ONLINE SURVEY
Guidance states that patients should be offered two options for returning the questionnaire. Therefore you will also receive a number of stickers with instructions for patients on how to complete a questionnaire online after their visit. These can be affixed to prescription bags and will include a unique PIN number specific to your pharmacy.

I confirm that I have read and accept the terms and conditions of the service that will be provided by CFEP UK Surveys.

Signed Date
We offer translations of the questionnaire in a wide range of languages, and a large-print version for the visually-impaired. If you feel that you would like to ask your patients specific questions, we can work with you to add these to your survey. (Price on application.)

Please add VAT @ 17.5%


Please tick here if you would like a VAT receipt

Registered Address: CFEP-UK Surveys Ltd, 6 Providence Court, Pynes Hill, Exeter, Devon EX2 5JL Registered in England Company No 05781518 VAT Reg No 777 3032 19

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