Order Testex | HFA Healthcare-Oct24

TESTEX

Unlicensed Product Order Form

Your invoice will be issued by and payable to our distributor Movianto UK Limited

Full Name of Ordering Person

Delivery Address (Hospitals/Pharmacies/Dispensing Practices Only)

Address Line 2

Post Code

Contact Person for Order Delivery

Phone

Select the presentation you want to order:

Testex Prolongatum 100mg/2ml solution injectable - £27 per vial

Testex Prolongatum 250mg/2ml solution injectable - £29 per vial

Quantity of Testex Prolongatum 100mg/2ml solution injectable to be ordered (Minimum Order Quantity = 10 vials)

Quantity of Testex Prolongatum 250mg/2ml solution injectable to be ordered (Minimum Order Quantity = 10 vials)

Declaration: (to be signed by a person who is legally authorised, in accordance with MHRA Guidance Note No.14 – ‘The Supply Of Unlicensed Relevant Medicinal Products For Individual Patients’).

I confirm that this order for unlicensed product is intended to meet the ‘special needs’ of an individual patient in accordance with the specification of a doctor, dentist (or group of), or supplementary prescriber registered in the UK and for use on his direct personal responsibility.

Signatures

Professional Status

Order Date

Prescribing Doctor’s Name

Thank you. We have received your order and will be processing it shortly.