Samsca® Order Form

You can order Samsca® using the form below.

For assistance in completing the form please refer to the Frequently Asked Questions (FAQs).

Please note:

Orders can only be accepted from hospital pharmacies.
There may be specific procedural requirements for the purchase of medicinal products that have a marketing authorisation, but are not currently available in your country. It is your responsibility to ensure that you have complied with any such requirements.

ORDER HELPLINE
+44 1895 207100

Product Required

Please select which pack combination you would like to order:

Product Cost (€)

Cost of Samsca€
Total Invoice Amount€
(including packaging and shipping, excluding VAT)

Hospital Details (Delivery Address)

Country*
?
Please Note

Orders are only accepted from certain EEA countries so if you do not see your country available in the list please see our FAQ's for full details.
Hospital Name*
Department
Address 1*
Address 2
Address 3
Town/City*
Postcode/Zipcode*

Requesting Hospital Pharmacist

Name*
Telephone*
Fax
Email*
Verify Email*

Requesting Hospital Physician

Title
Name

Invoicing Details

Please Note

Your invoice address is pre populated based on your hospital address, please edit the invoice address here if it is not the same

Purchase order number
VAT Country code*
?
Please Note

The VAT country code is pre populated based on the country of your delivery address, you can modify it if required by selecting from the drop down.
VAT Number*
?
Please Note

Your VAT number must be between 8 and 12 characters long, this is required for us to process your order. If you do not have a VAT Number, please call the helpline.
Contact Name
Hospital Name
Department
Address 1*
Address 2
Address 3
Town/City*
Postcode/Zipcode*
Country

*Indicates mandatory fields