Account Application Form

Transcription

1 Dear Customer, Thank you for your recent enquiry regarding opening an account with NHS Supply Chain. NHS Supply Chain provides customer-focused healthcare products and supply chain services to the UK s National Health Service (NHS), enabling trusts, hospitals and other healthcare organisations to focus on patient care. Key benefits include: Award-winning online ordering system and electronic catalogue Access to over 600,000 competitively priced products Regular scheduled deliveries to meet your needs Dedicated customer service support. Under the terms of our charter, NHS Supply Chain is only able to provide this service to front line patient care providers. It would therefore be most helpful if all the fields indicated on the attached application form could be completed as this will enable us to process your application in a timely manner. NHS Supply Chain delivers to a wide variety of Healthcare locations from Hospitals to small GP clinics and Dental surgeries. It may therefore be necessary to carry out a road and access suitability assessment and to confirm where you would like your goods delivering. If this is required for your location, we will notify you and make a suitable appointment to carry out this survey with you. Once we have approved your account application we will contact you to help you place your first order and enable you to get the most from our products and services. Please note orders over 120 are delivered free of charge, orders below 120 may incur a charge of 7.50 towards the cost of delivery. Payment terms are 30 days from date of invoice. As an added benefit for registered Charities and NHS charitable funds we can offer VAT zero rating on medical/ scientific items, so please ensure that you complete our 6 month certificate and return with your application form. If you have any further queries then please do not hesitate to contact us on either of the telephone numbers below. Yours sincerely, Private Sales Team Tel: csadmin@supplychain.nhs.uk 1

2 Please tick which applies to your organisation. New Account NHS Organisation with over 50% funding by the NHS (such as most GPs) complete sections 1,2,4 and 6. Wider Public Sector Public sector health related customer, e.g. Local authority, MOD, prison, school (home countries), complete sections 1, 2, 3, 4 and 6. Private Greater than 50% NHS Business Activity Provider has greater than 50% of NHS Business Activity, complete sections 1, 2, 3, 4 and 6. Section 1 Nature of Business Brief Description of Services to be Provided Organisation Name Delivery Address Additional Account Private Less than 50% NHS Business Activity Provider has less than 50% of NHS Business Activity, complete sections 1, 2, 3, 4 and 6. Private Profit making organisations using heath care services to achieve core purpose profit eg Spire, Bupa, BMI, non-nhs Dentist, complete sections 1, 2, 3, 4 and 6. NHS Service Provider Organisations contracted to provide healthcare services and guarantee to only use products on those contracts, complete all sections 1-6. Not for Profit Provider of healthcare services on a not for profit basis e.g. voluntary, hospice, charity, social enterprise, complete sections 1, 2, 3, 4 and 6. Purchases with charitable funds Eligible organisations to benefit from VAT zero rating on medical/scientific items. Contact Name Address Invoice Address (if different to above) Job Title Website Contact Name Address of Parent Company (if applicable) Company Registration Number Job Title VAT Number Are you a registered charity? Yes No Charity number Please ensure you complete our VAT Exemption Certificate and return with this application to avoid delays in setting up your account 2

3 Section 2 Anticipated frequency of order? Weekly Monthly Other (please advise); What types of products might you purchase from us? (please tick all that apply) Cleaning, hygiene and infection control products Clinical products Continence products Dental and optical equipment Drapes and gowns Dressings Food and catering products Furniture and fittings Hearing aids Lab instruments and equipment Office equipment and stationery Operating theatre products Protective clothing e.g. gloves/ masks/aprons Rehabilitation e.g. crutches, walking frames Women and child/sexual health promotion Expected annual spend? NHS Supply Chain only s invoices, please submit an address for our records address for invoices Section 3 What percentage of your sales turnover is NHS Business? Please attach evidence to support this statement Section 4 Do you wish to purchase now or at any time in the future products classed as Licensed Medical Products (LMPs) see appendix 1 for examples Yes No If yes you must complete all the sections What type of products will you be ordering from us. Failure to provide sufficient, verifiable evidence of your suitability to order LMPs will result in you being unable to place demand for this range, even though you may be able to view them in our catalogue. Acceptable evidence is one of the following: A copy of your MHRA Distributor or Manufacturers Licence (if applicable) A headed letter containing the following GMC/GDC/GPhC registration number, forename(s) and surname. As part of MHRA requirements placed on NHS Supply Chain as a distributor of Licensed Medicinal Products we are required to undertake customer validation checks and as such we reserve the right to restrict supply of Licensed Medicinal Products to validated customers. Please note evidence provided will be routinely subject to re validation, subsequent failure will see the range removed from your access. 3

4 Section 5 Which NHS customer are you providing services to? What services are you providing? What is the contract period? What are the options to extend the contract period? What are the contract review periods? Section 6 Terms of payment are strictly 30 days from date of invoice. Orders below 120 may incur a carriage charge of 7.50 (inclusive of VAT). The account must be used monthly or we reserve the right to terminate the account. Roll cages and tote bins are to be returned promptly following delivery. This agreement does not permit you to use these products for any other customer other than stated above. Evidence of such practices will result in the termination of your account. By typing my name/signing below, I certify the above information to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my application. Signed by: Print Name: Position: Date: Please note that your contact details will be kept securely in our database and will not be disclosed to a third party. If you would prefer us not to contact you from time to time with further information about products and services which may be of interest to you, please tick this box. Click here to submit form via 4

5 Appendix 1 Licensed Medical Products (LMPs) Correct as at 12 May 2012 and subject to change Catalogue Code Description ABX072 Vitamins Drops 10ml Healthy EFA016 Bandage zinc paste BP 7.5cm x 6m EFA018 Bandage zinc oxide impregnated medicated stocking 17 x 13 x 1cm FDN078 Saline sodium chloride 1 litre FDN079 Saline sodium chloride 500ml MRB296 Oral hygiene mouthwash chlorhexidine 0.2% peppermint mouthwash 300ml MRB297 Oral hygiene mouthwash chlorhexidine 0.2% original mouthwash 300ml MRB300 5 chlorhexidine 0.5%/denatured ethanol 70% spray 200ml pink MRB301 Skin antiseptic chlorhexidine 0.5%/denatured ethanol 70% spray 500ml pink MRB302 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile 0.67ml MRB303 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile 1.5ml MRB304 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile 10.5ml MRB305 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile 26ml MRB306 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile 3ml MRB314 Skin care arachis oil 200ml MRB315 Skin care calamine lotion 200ml MRB317 Skin care zinc and castor oil ointment 100g tub MRB318 Skin care zinc and castor oil ointment 15g tube MRB319 Surgical scrub chlorhexidine 4% surgical scrub solution 250ml MRB320 Surgical scrub chlorhexidine 4% surgical scrub solution 500ml MRB321 Surgical scrub chlorhexidine 4% surgical scrub solution 500ml MRB328 Surgical scrub Povidone iodine 7.5% surgical scrub solution 500ml MRB332 Skin pre-operative chlorhexidine 0.5%/denatured ethanol 70% solution 600ml clear MRB333 Skin pre-operative chlorhexidine 0.5%/denatured ethanol 70% solution 600ml pink MRB335 Skin pre-operative povidone iodine 10% alcoholic solution 500ml MRB336 Skin pre-operative povidone iodine 10% antiseptic solution 500ml MRB337 Catheter urethral anaesthetic lubricating gel lidocaine 2%/chlorhexidine 0.05% gel 11ml MRB338 Catheter urethral anaesthetic lubricating gel lidocaine 2%/chlorhexidine 0.25 grams gel 6ml MRB340 Women and child health clinical chlorhexidine 1% antiseptic dusting powder 15g MRB353 Irrigation fluids chlorhexidine cetrimide 0.15%/chlorhexidine 0.015% solution 100ml sachet MRB354 Irrigation fluids chlorhexidine cetrimide 0.15%/chlorhexidine 0.015% solution 25ml sachet MRB355 Irrigation fluids chlorhexidine 0.05% solution 100ml sachet MRB356 Irrigation fluids chlorhexidine 0.05% solution 25ml sachet MRB387 Surgical scrub chlorhexidine gluconate 4% w/v detergent based solution with emollient 250ml MRB494 Saline sodium chloride 1 litre FSQ565 Catheter central venous placement pack maximum barrier protection cdc for the placement of central venous catheters non returnable due to containing chloraprep MRB495 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile with tint 10.5ml FSP2213 Cannula intravenous infusion set with injection port sterile and safety device Yellow 24g x 19mm winged clip technology pack containing: drape - chloraprepp SEPP 2% chlohexidine steret - swabs x5 - opsite (IV3000) dressing - cannula care plan - sterile field - traceability labels FSP2214 Cannula intravenous infusion set with injection port sterile and safety device White 17g x 45mm winged clip technology pack containing: drape - chloraprepp SEPP 2% chlohexidine steret - swabs x5 - opsite (IV3000) dressing - cannula care plan - sterile field - traceability labels FSP2234 Cannula intravenous infusion set straight sterile and safety device Yellow 24g x 19mm winged clip technology pack containing: drape - chloraprepp SEPP 2% chlohexidine steret - swabs x5 - opsite (IV3000) dressing - cannula care plan - sterile field - traceability labels FSU410 Pack placement PICC Opaque tray filter straw 3 green prep forceps 2 x 10ml I/s syringes yellow disposal bag metal scissors gallipot adhesive tape strip utility drape aperture drape 2 non woven swabs 15 white 8 ply swabs with chloraprep non returnable contains chloraprep MRB496 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile with tint 26ml MRB561 Skin antiseptic 2% chlorhexidine gluconate in 70% IPA sterile 1.5ml 5