SOS Oxygen Penthrox Order Form
** Only qualified and authorised persons may purchase this product **
Your Contact Information
To be completed by the qualified person only
Name
*
First Name
Last Name
Company Name
Billing Address (DO NOT ENTER COMPANY NAME)
*
Street
City
County
Post Code
Phone
*
Email
*
example@example.com
Is your Shipping Address the same as the Billing Address?
*
Please Select
Yes
No
Shipping Address
*
Street Address
City
County
Post Code
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Training Certification
Do you hold prescribing rights
*
Please Select
Yes
No
Unfortunately, Penthrox can only be purchased and dispatched to somebody holding prescribing rights.
Type of Qualification
*
Please Select
Doctor
Dentist
Nurse
General pharmaceutical council
Paramedic with prescribing rights
Please provide your GDC registration number
*
Please provide your GMC registration number
*
Please provide your NMC registration number
*
Please provide your HCPC registration number
*
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Confirmation
Please upload a copy of your driving licence for identification purposes
*
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Penthrox [1201]
£31.00
£
31.00
Quantity
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Item subtotal:
£0.00
£
0.00
Have you purchased Penthrox from us previously?
*
Yes
No
Please verify that you are human
*
Date
*
-
Day
-
Month
Year
Date
Signature
*
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Submit
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