Option One: Upload an image of the patient details including address, date of birth, contact information and GP details here:
Option Two: If you cannot provide an image of the patient details or any information is missing, please complete the relevant details below:
To place your patient's first order please choose up to three products from the drop down lists. If the product is not listed or if you would like to order additional items please enter the order code, item description and quantity in the box below. If you would like the patient to order as part of the welcome call please do not select any products and continue to GP details.
The personal data you provide (name, hospital, telephone, email) and that of your patient (name, address, telephone, email) on this request form will be collected and stored in accordance with the requirements of the Data Protection Act 2018.
B. Braun will not share your or your patient's personal data with any third party. In providing this data you consent for such data to be used for the purpose of dealing with your request and providing the service.
You can alter your personal data preferences or unsubscribe from the service at any time by sending an email to firstname.lastname@example.org.