Please fill out as much as you can, required information is indicated
First Name (required)
Last Name (required)
Date of birth (required)
Your Email (required)
Phone or Mobile
Do you have any communication difficulties?
How would you prefer to be contacted by us?
If other, please explain
Best time to call?
Can we leave a message?
Street Address (required)
Your GP's Name:
GP Surgery Name
GP's Telephone Number
Electronic prescriptions are by far the fastest route to getting Manfred Sauer products as we will always have stock for same day dispatch (if we receive your script before 1pm) for next day delivery. If your GP is registered for the Electronic Prescribing Service
(EPS) we or your GP can nominate all future prescriptions for Medical Appliances (not drugs) to be sent instantly to us via the EPS service. Paper prescriptions can also be sent via our freepost envelopes. Some other manufactures products may take us a bit longer to dispense depending on their availability and can be shipped separately if required.
If your GP can write Electronic Prescriptions (EPS) would you like to use this service?
Medical Condition(s) (this information will help our staff understand your personal needs)
Are you exempt from prescription charges? please state or you must pay fees (unless if under 16 over 60 which is an automatic exemption)
What are your medical appliance needs?
Delivery special instructions. We will need a signature to leave the parcel. Perhaps you would like it delivered to a workplace/friend/relative? The parcel can also be left at a shop or pharmacy, near to your home, so you can collect it later. You can call us for details or check on the DPD website for details of participating businesses www.dpdlocal.co.uk or call our helpline.
Interlink Express/DPD will discreetly deliver your appliances so if you have an internet enabled device once we have given you the tracking number you can see exactly where it is and when it will be delivered within a 2hr slot and even delay its arrival or change delivery address. DPD also have an App to allow you to track the delivery easier.
Would you like to be kept up to date on your prescription delivery status - if so, how?
Complementary items with each delivery
Would you like to discuss any aspect of product usage with one of our helpline advisers? (all have personal experience using the products
to manage continence in the real world). If so please indicate best number & time to call and if possible briefly describe what you
would like to discuss.
Have you used another prescription home delivery service?
Where did you first hear about Manfred Sauer?
We will never sell or give your personal information to anyone (see statement of service conditions at end of this questionnaire). If you are happy to be contacted by us with information about new products & services that we offer, please specify Yes/No and how you would like to be contacted*
The Small Print about the personal information you provide above (but not in print so small that we don’t want you to read it). To provide you with this service it is required that we comply with our NHS Dispensing Appliance Contract terms and conditions which states that we need to collect and share this information from time to time with your GP and other NHS healthcare professionals involved in your care. This will be done sensitively and handled in accordance to NHS Information Governance and the Data Protection Act 1998 and the key principals of Caldicott; in protecting the security and confidentiality of personal information. While we are serving you, your personal information may be disclosed to specific NHS medical personnel in the unlikely case for reporting of an adverse event, a complaint and/or the necessity to change or re-supply specific medical appliances; under these circumstances MSC will need to share identifiable data and information to comply with mandatory reporting obligations regarding patient safety as legislated by the appropriate government regulatory
authorities. Should this ever be necessary we will inform you first. The delivery partners we use will only receive your address and any other information you have authorised us to pass on such as telephone/mobile number and special delivery instructions You can revoke your consent at any time verbally to take immediate effect but ideally, we would also ask you to follow that up in writing as soon as possible.