Online Special Order Form

Customer Details

Sigma Account Code

Pharmacy Name

GPHC

Pharmacy address (including postcode)

Contact Name

Contact Number

Email

Product Details

Product Detail *

Includiing strength, dosage form and any other requirements

Pack Size

Qty

Clinical Need**

Item 2 Product Details

Item 2 Pack Size

Item 2 Qty

Item 2 Clinical Need**

Item 3 Product Details

Item 3 Pack Size

Item 3 Qty

Item 3 Clinical Need**

* If the product is a controlled drug, the Pharmacist must approve by including their registration number

** Please ensure that the prescriber is aware that an unlicensed product is being supplied and that he/she is reminded of his/her obligations. A member of the Specials team will contact you if we require a proof of prescription for unlicensed medicinal products.

Note: All special items are strictly non-returnable. All Special Obtain orders may incur handling charges. Specials opening hours are Monday - Friday 9am - 6.30pm.