HMMS Drug File Addition Form : Suppliers Only

1
Name of Supplier* This field is required.Please provide Supplier name
2
Name of Requestor* This field is required.Please provide your full name
First Name
Last Name
3
Job Title* This field is required.
e.g. Managing Director, Medical Representative, Telesales Colleague
4
Email* This field is required.Email Contact 1
example@example.com
5
Email* This field is required.Email Contact 2 (if Contact 1 is unavailable)
example@example.com
6
Phone Number* This field is required.Please enter a valid Phone Number
Area Code
Phone Number
7
Supplier Information* This field is required.Please fill out all fields to ensure the Supplier Details are accurate on HMMS
8
Which best describes this Supplier for this product?Describe Supplier
Wholesaler
Direct Delivery
9
Details of Addition Request* This field is required.Please fill out all fields. If sufficient information is not supplied, we cannot proceed with your request
10
Is this Medication Unlicensed?* This field is required.
Please Select
Please Select
Yes
No
11
Is this a Kit?* This field is required.
Please Select
Please Select
Yes
No
12
Detail naming convention of Kite.g. Endoscopy
Huge
Large
Normal
Small
Ok
Ok
13
Image AttachmentSubmit images to support request
14
EAN Image AttachmentSubmit image of EAN Barcode
15
GTIN Image AttachmentSubmit image of GTIN Barcode
16
Additional informationPlease input any additional information or comments to support your request e.g. Launch date of new drug
Huge
Large
Normal
Small
Ok
Ok
17
File Attachment* This field is required.Submit SPC or documents as required to support request
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
18
Confirmation Email Consent* This field is required.A confirmation email will be sent to you once your Jotform is submitted. Please tick the box below to confirm consent
Agree
Should be Empty: