Diabact - 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

Movianto Account Number

Product Code: DIABACTKIT

Product Name: DIABACT UBT KIT

Quantity of Units Ordered (1 Unit = 1 Kit)

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

Thanks for submitting the order!