Address Validation Form

Our quality team must validate that stock medicines are being delivered to 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 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

Step 1 of 3

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Your Details

Please provide your details for address validation.

What is your Healthxchange Account Reference?(Required)

This is normally 3 digits 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 full address and postcode of the address you wish to submit for validation?

Address line 1(Required)

Address line 2(Required)

Address line 3

City(Required)

County(Required)

Postcode(Required)

Country(Required)

United KingdomIrelandGuernseyJersey

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

Doctor

Dentist

Other

Specify responsible for medicines management at this address(Required)

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

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)

BDA

CQC

GPHC

HIS

HIW

MHRA

RQIA

Other

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)

BDA

CQC

GPHC

HIS

HIW

MHRA

RQIA

Other

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)

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

Email

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