Clinigen Limited, Pitcairn House,

Crown Square, Centrum 100,

Burton On Trent, Staffordshire DE14 2WW
Company Registration Number: 06771928
www.clinigen.com

NEW CUSTOMER ACCOUNT FORM

Please complete the form below to request a new account with Clinigen.
Fields marked * are mandatory. If you require support completing this form, please get in touch.

YOUR INSTITUTE’S DETAILS

Institute type Select option City/Town*
Dental
Government
Distributor
Hospital
Not
Intercompany
Overheads
Pharma
Prison
Retail
Veterinary
Wholesaler
forPharmacy
Services
Practice
Profit
-- CRO
Biotech
CMO
Pharmacy
Private
Public
Practice
- National
International
- National
Independent
Local Chain
Chain
Institute name* County/State/Province*
Address line 1* Country/Region*
Address line 2* ZIP/Postal Code*
Address line 3 VAT number* Applies to UK & EU countries only

Invoice details Delivery details Address is the same as invoice address

First name* First name*

Surname* Surname*
Email address* Email address*
Telephone number* Telephone number*
Fax number* Fax number*
Address line 1* Address line 1*
Address line 2* Address line 2*
Address line 3 Address line 3
City/Town* City/Town*
Postal Code/ZIP* Postal Code/ZIP*

YOUR PERSONAL DETAILS Please invite my colleagues to create an account on

I am the lead contact for the above institute Clinigen Direct. I have permission from the individuals
and have its permission to trade with Clinigen* Yes named below to share their personal information. Yes

Title* First name

First name* Surname
Surname* Email address
Email address* Please do not use a generic email Telephone number*
Phone number* First name
Job type* Select option Surname
AP Value
No
Dentist
Client
Buyer
Pharmacist
Nurse
Physician's
Physician
Project
Purchasing
Site
Undefined
Veterinary
Clerk
Co-Ordinator
Manager
Nurse
Surgeon
Assistant
Technician
Manager
Licence number Email address
Specialism* Select option Telephone number*
Anatomical
Anaesthesiology
Cardiothoracic
Cardiology
Chemical
Diagnostic
Dermatology
Emergency
General
Gastroenterology
Endocrinology
Geriatric
Internal
Haematology
Medical
Nuclear
Neurosurgery
Neurology
Nephrology
Obstetrics
Orthopaedic
Ophthalmology
Otorhinolaryngology/ENT
Paediatric
Plastic
Paediatrics
Public
Psychiatry
Radiation
Pulmonology
Rehabilitation
N/A
Urology
Rheumatology
Health
Surgery
Medicine
Oncology
Medicine
Surgery
Medicine
Pathology
Oncology
Cardiology
Neurology
Oncology
Surgery
and
Radiology
Pathology
Medicine
Surgery
Medicine
Surgery
Gynaecology
First name
I would like access to Clinigen Direct
to place/manage my orders online Yes
Surname
(available to Healthcare Professionals only, e.g. physicians, pharmacists, Email address
pharmacy technicians and pharmacy procurement managers)
Telephone number*

ELECTRONIC ORDERS
Please provide an EDI ANA Location number if available UK only
Please provide an XML reference if available

DECLARATION AND SUPPORTING DOCUMENTS

You accept our Terms of Sale and our Privacy Policy
I have read and accept the Privacy Policy I have read and accept the Terms of Sale
Clinigen will require a copy of your wholesale distribution authorisation, or evidence that you are authorised or entitled to supply medicinal products to the public
(entitlement according to national legislation), to progress account set up. Failure to supply appropriate evidence will require Clinigen to undertake additional
verification steps to confirm the customer bona fides.

I have attached a copy of my wholesale distribution authorisation or equivalent evidence

Authorisation
I am authorised to place orders on behalf of the above institute, and confirm that the above information is correct.
Signature Date

Name Job title

All new accounts with sites and locations within the EEA will be customers of Clinigen Ireland Ltd and orders will be dispatched from one of our EEA warehouses. All
customers outside of the EEA will be Clinigen Healthcare Limited customers. If for operational reasons, we need to send your order from one of our EEA warehouses
your order will be fulfilled by Clinigen Ireland Limited and Purchase Orders will be required to be addressed to Clinigen Ireland Limited. Please request further details
if required from creditcontrol@clinigengroup.com