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 click here for Prescribing Information http://www.samsca.co.uk/prescribing-information.html

Please note:
Orders can only be accepted from hospital pharmacies.

ORDER HELPLINE
01773 515 171
(Customer Service)

Product Required

Please select which pack combination you would like to order:

Samsca® 10 x 15mg
Samsca® 10 x 30mg

Product Cost (£)

Cost of Samsca£
Total Invoice Amount (including VAT at 17.5%)£
(including packaging and shipping and VAT)

Hospital Details (Delivery Address)

Hospital Name*
Department*
Address 1*
Address 2
Address 3
Town/City*
County*
Postcode*

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
UDG Customer Number (if applicable)?
Please Note
Unidrug Distribution Group
VAT Number*
Contact Name
Hospital Name
Department
Address 1*
Address 2
Address 3
Town/City*
County*
Postcode*
Country

*Indicates mandatory fields