Healthxchange Quality

Stock Medicine Ordering – Account Verification Form

Step 1 of 3

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

A stock medicine order is where medicines are supplied for use in clinic without associated prescriptions at the point of supply.

The supply of stock medicine to a clinic is classified as a wholesale transaction by the MHRA. Healthxchange are required to complete additional checks before we can dispatch stock medicine orders.

Stock medicines must only be sent to authorised persons* at approved premises. This is to maintain the integrity of the pharmaceutical distribution chain; preventing either misuse or diversion.

*We only supply stock medicines to Doctors, Dentists or Persons carrying on the business of an Independent Clinic registered with Health Improvement Scotland.

Below, you will find a list of supporting documentation that will be required to validate an account to receive stock medicine orders. Please ensure you have these in order to complete this form.

Person(s) Authorised to Order	Business	Address you wish to validate to receive stock medicines
Valid Photo ID Professional Registration number Contact details	Limited Companies Company Registration Number Sole Traders and Partnerships Evidence to confirm status of business for e.g. UTR or HMRC correspondence.	CQC/HIS/HIW/RQIA registered Registration certificate Utility bill for the named business and address If the business address is exempt from the requirement to register with CQC or RQIA Medicines Management Policy Certificate of Professional Indemnity or a Statement of Fact. Utility bill for the named business and address

Person(s) Authorised to Order

Business

Address you wish to validate to receive stock medicines

Valid Photo ID
Professional Registration number
Contact details

Limited Companies

Company Registration Number

Sole Traders and Partnerships

Evidence to confirm status of business for e.g. UTR or HMRC correspondence.

CQC/HIS/HIW/RQIA registered

Registration certificate
Utility bill for the named business and address

If the business address is exempt from the requirement to register with CQC or RQIA

Medicines Management Policy
Certificate of Professional Indemnity or a Statement of Fact.
Utility bill for the named business and address

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)

Delivery Address (to be validated):

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)

Type of Business(Required)

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

Please upload a document received from HMRC that shows; UTR number, trading name and address(Required)

Drop files here or

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

Evidence required from HMRC that states UTR, business trading name and address.

Please name the authorised person(s) who will be signing for these orders?(Required)

Doctor

Independent Nurse Prescriber (registered with Health Improvement Scotland Only)

Dentist

**We only supply stock medicines to Doctors, Dentists or Persons carrying on the business of an Independent Clinic registered with Health Improvement Scotland.

Practitioner Name(Required)

Professional Registration Number (GMC, GDC,)(Required)

ID Upload

Drop files here or

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

Please upload your ID

Please provide an email address and phone number for the authorised person(s)

Please add the email address and phone number for the authorised person at this address. Note this must be unique to the authorised person and we cannot accept generic inboxes or telephone numbers.

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 (Doctors and Nurses)(Required)

My premise is registered with CQC, HIS, HIW or RQIA

My premise is exempt from registration with CQC in England

My premise is exempt from registration with the RQIA in Northern Ireland.

Please choose which validation method (Nurses and Other)(Required)

My premise is registered with CQC, HIS, HIW or RQIA

Registered bodies (Premises Registration Number)(Required)

CQC (England)

HIS (Scotland)

HIW (Wales)

RQIA (Northern Ireland)

Registered bodies (Premises Registration Number)

Please upload supporting evidence of your registration(Required)

Drop files here or

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

Please upload supporting evidence of your chosen documentation. Please ensure you include Medicines Management Policy and Certificate of Professional Indemnity or Statement of Fact.(Required)

Drop files here or

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

Please complete the following declaration for RQIA exemption for Doctors.(Required)

I, , , in my capacity as , confirm that the trading from is exempt from the requirement to register with the RQIA. I confirm that the following statements are true:

This clinic does not provide any of the following listed service as specified in Regulation 4 of The Independent Health Care Regulations (Northern Ireland) 2005:

Provision of prescribed techniques or technology: Class 3B or Class 4 laser or Intense Pulse Light Machine
Provision of prescribed techniques or technology: Endoscopy
Provision of prescribed techniques or technology: In vitro fertilisation techniques
Surgical procedures under anaesthetic or conscious sedation
Provision of private dental care and treatment
Medical treatment under anaesthesia or sedation
Dental treatment under anaesthesia or sedation
Obstetric services and, in connection with childbirth, medical services
Cosmetic surgery (excluding the subcutaneous injection of a substance into the skin for cosmetic purposes)

Alongside my role as at , I remain affiliated with the Health and Social Care (HSC) sector in Northern Ireland (NI) and/or am listed on the Northern Ireland Primary Medical Performers List (PMPL) [attach evidence].

The establishment does not offer Patient Group Directions (PGDs) and does not provide online/remote medical services.

Please complete the following declaration for RQIA exemption for Densists.(Required)

I, , , in my capacity as , confirm that the trading from is exempt from the requirement to register with the RQIA. I confirm that the following statements are true:

This clinic does not provide any of the following listed service as specified in Regulation 4 of The Independent Health Care Regulations (Northern Ireland) 2005:

Provision of prescribed techniques or technology: Class 3B or Class 4 laser or Intense Pulse Light Machine
Provision of prescribed techniques or technology: Endoscopy
Provision of prescribed techniques or technology: In vitro fertilisation techniques
Surgical procedures under anaesthetic or conscious sedation
Provision of private dental care and treatment
Medical treatment under anaesthesia or sedation
Dental treatment under anaesthesia or sedation
Obstetric services and, in connection with childbirth, medical services
Cosmetic surgery (excluding the subcutaneous injection of a substance into the skin for cosmetic purposes)

The establishment does not offer Patient Group Directions (PGDs) and does not provide online/remote medical services.

Please upload evidence of affiliation with HSC in Northern Ireland and/or listed on the Northern Ireland PMPL list.(Required)

Drop files here or

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

Signature(Required)

Email contact(Required)

Date(Required)