Order Form

Please fill out this form with your patients details, name addres & DOB at the top and your (aesthetic practitioners) details at the bottom. If you can let us know your prescribers name and phone number, we can contact them to have your precsription sent to us. Alternatively you can have the prescription sent to you and upload it yourself at the bottom of this form.

Patient Name (prescription)

Patient Address (line 1)

Patient Address (line 2)

Patient Address Town/City

Patient Address Postcode

Patient Date of Birth

Prescriber Full name

Prescriber phone number

Upload copy of your prescription here (if you have one)

Which Diluent would you like to order?

What Toxin would you like to order?

What Weight loss injection would you like to order?

What Anaesthetic creams would you like to order? (select one or more)

Emla 5% 5g - £4.99

Emla 5% 30g - £17.49

LMX 4% cream 5g - £3.99

LMX 4% cream 30g - £16.99

What Vitamin medicines would you like to order? (select one or more)

(B12) Hydroxocobalamin 1mg/1ml x 5 Amps - £22.50

(B12) Hydroxocobalamin 1mg/1ml x 1 amp - £3.99

What dermal fillers would you like to order? (select one or more)

Kairax SubQ + Lido - £35.00

Kairax Fine + Lido - £35.00

Kairax Deep + Lido - £35.00

E.P.T.Q 100 - £37.00

E.P.T.Q 300 - £37.00

E.P.T.Q 500 - £37.00

We have prebuilt you emergency packs at Ask pharamcy to save you time for your busy clinic! The emergency pack is built using items reccomended from the guidelines from the Ace group. http://acegroup.online/guidelines/

The medicines and items in this pack have been carefully selected by top aeshtetic Doctors and surgeons to ensure you and your patients are safe at all times when practicing aesthetics.

The basic kit inludes the following medicines;

1 x EPIPEN, Hyaluronidase 1500 units x2 ampoules, Sodium Chloride Ampules 5ml x4, Aspirin 75mg x 28, Timolol eye drops 0.5% 5ml x1, Normal Saline Steripod Eye Wash 2 x 10ml, Loratadine 10mg tablets x28

and the following consumables that will come in handy when using the above medicines.

2ml Luer-lok Syringe x2, 10ml Luer-lok Syringe x2, 1ml Graduated Syringe x3, 23G Blue Needles x4, 27G Grey Needles x2, 30G Yellow Needles x2

The Advanced kit includes all of the above PLUS an Epipen

Would you like a pre built emergency kit

Emergency kit - BASIC - £185

Emergency kit + Epipen - £245

Do you want any separate emergency medication? (select one or more)

Hyaluronidaise 15000u x 1 amp - £39.99

Adrenaline 1mg x 10 amps - £19.99

Epipen 0.3mg - £69.99

Loratadine tabs 10mg - £4.99

Aspirin 75mg tabs - £4.99

Do you have an allergy to Bee or Wasp stings?

Is there any medicines you need that are not on this list above, please type them and the quantity required here

If you want multiples of any of the products you have selected, please type here which product and how many multiples you require

Delivery Address (Line 1)

Delivery Address (Line 2)

Delivery Address Town / City

Delivery Address Postcode

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