Community Pharmacy Patient Questionnaire - Order  Form

 

To place your CPPQ order complete the details below indicating the size of your pharmacy – this will determine the materials that you will need. When you submit your details we will process your request by sending out a confirmation letter with the details of your pharmacy name and address which will appear on your survey form (a condition of the survey being compliant). With this letter you will receive an invoice, which should be paid by return post.

Your details
Title 

Forename:
Surname:
Pharmacy Name:
Address
Postcode:
Telephone: 
Fax: 
Email: 
PCT Name:

Date you would like your survey action pack  (please allow 21 days for delivery)

Please choose the pack that matches your pharmacy's dispensing volumes
Type Monthly prescription items Standard Price
(excl VAT)
Standard Price
(incl VAT)
Tick to order
A 0 - 2000 £ 75.00     £88.13
B 2001 - 4000 £100.00     £117.50
C 4001 - 6000 £120.00     £141.00
D 6001 - 8000 £145.00   £170.38
E 8001+ £160.00   £188.00
 

 


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