Address Validation Form

Our quality team must validate that wholesale stock medicines are being delivered to a business at a premise where we are allowed to do so under the regulatory guidelines and where they remain under your control, as an appropriately qualified medical professional, in a safe and appropriate environment.

Please note, we can only supply stock medicines to Doctors and Dentists. In Scotland, Nurses carrying on the business of an independent clinic registered with Health Improvement Scotland, may also order and stock medicines in connection to the running of a clinic. (Nurses operating in the rest of the UK are unable to order medicines as stock and should order on prescription for the named patient).

Please help us validate your address by completing this form.

If you have any questions, please contact our dedicated Quality team by email quality@healthxchange.com

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Your Details

Please provide your details for address validation.

What is your Healthxchange Account Reference?(Required)

This is normally 3 letters and 2 numbers e.g. ABC12 and will be the first part of your e-pharmacy user name.

What is the name of the business registered at your proposed delivery address?(Required)

What is the name of the business registered at your proposed delivery address? (Required) *

Please note, this business must be legally authorised to hold stock medication at that address.

Clinic Name(Required)

Address line 1(Required)

Address line 2(Required)

Address line 3

City(Required)

County(Required)

Postcode(Required)

Country(Required)

United KingdomIrelandGuernseyJersey

Type of Business(Required)

Please select from the dropdownLTD Company – Company Number (from Companies House)Partnership  – UTR number (Unique Tax reference from HMRC)Sole Trader – UTR number (Unique Tax reference from HMRC)

Companies house number

Please note, this is only if you are a LTD company

Unique Tax reference from HMRC

Please note, this is only if your company type is Sole Trader or Partnership

Evidence required for UTR from HMRC and recent utility bill (within 3 months) in the name of the business at the premises.(Required)

Drop files here or Select files

Accepted file types: jpg, pdf, png, Max. file size: 2 MB, Max. files: 10.

Who is responsible for medicines management at this address?(Required)

Doctor

Nurse (ordering for a HIS registered business in Scotland, only)

Dentist

Other

Specify responsible for medicines management at this address(Required)

Please note, we can only supply stock medicines to Doctors and Dentists. In Scotland, Nurses carrying on the business of an independent clinic registered with Health Improvement Scotland, may also order and stock medicines in connection to the running of a clinic. (Nurses operating in the rest of the UK are unable to order medicines as stock and should order on prescription for the named patient)

Please enter your Professional Registration Number (GDC, GMC)(Required)

Medicines management email(Required)

Please add the email address for whoever is responsible for the medicines management at this address

Medicines management phone(Required)

Please add the phone number for whoever is responsible for the medicines management at this address

Address Validation and Document Submission

Please choose which validation method(Required)

The Premises Registration Number associated with your chosen delivery address.

A copy of your premises Registration associated with your chosen delivery address.

Registered bodies (Premises Registration Number)(Required)

CQC (England)

HIS (Scotland)

HIW (Wales)

RQIA (Northern Ireland)

Please enter Premises Registration Number associated with your chosen delivery address.(Required)

Specify other registered body (Premises Registration Number)(Required)

Registered bodies (Premises Registration)(Required)

CQC (England)

HIS (Scotland)

HIW (Wales)

RQIA (Northern Ireland)

Please upload a copy of your Premises Registration associated with your chosen delivery address.(Required)

Accepted file types: jpg, pdf, png, Max. file size: 10 MB.

Specify other registered body (Premises Registration)(Required)

Please upload a copy of your professional liability insurance(Required)

Accepted file types: jpg, pdf, png, Max. file size: 10 MB.

Please upload a copy of your Medicines Management Policy(Required)

Accepted file types: jpg, pdf, png, Max. file size: 10 MB.

Website associated with your delivery address.(Required)

We recognise that at present, our policy does not allow supply of wholesale medicines to clinics that fall outside of the above categories, although it’s worth noting that pharmacy supply remains unaffected. We are currently working to establish a revised risk-assessment process that would allow us to continue supplying those premises that fall outside this framework.

Contact Details

If our team need to contact you, what are the best contact details for you?

Your name(Required)

First Last

Email address(Required)

Phone Number

Name

This field is for validation purposes and should be left unchanged.