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FAQ
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Renal Registration Form
Please fill out the form below and click send
Are you ordering for yourself?
Yes (Move to next step)
No (Enter Referrer details below)
Referrer Name
Referrer Surname
Referrer Contact Number
Referrer Email Address
Hospital Name
First Name
Second Name
Date of Birth
NHS Number
Mobile Number
Landline Number
Email Address
Type of Dialysis
PD
HD
House Name or Number
Line 1
Line 2
Town or City
Post Code
Delivery Details
GP Surgery Name
City/Town
Postcode
Prescription Charge Exemption Status
Exempt
Not Exempt
Unknown
VAP1 - Medium Pouch - PK 10
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VAP2 - Large Pouch - PK 10
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VAP3 - Small Pouch - PK 10
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ND- 0001 - PK 30
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EA2 - Extra Sticky Pouch - PK 10
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BW2 - Fusion Applicator 3ml - PK 5
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BW3 - Fusion Applicator 1ml - PK 5
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SB2 - Acubond Strips - PK 5
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3505 - Medical adhesive remover wipes - PK 30
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3820 - Barrier wipes - PK 30
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RS1 - Remover Spray 50ml
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BW1 - Barrier Wipes - PK 30
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ARW1 - Adhesive Remover Wipes - PK 30
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Special Instructions
Do you want this to be an automatic monthly order?
Yes
No
If yes, how should we coordinate?
Not applicable
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