Orion Pharma UK Ltd
Dispensing Doctor Rebate Scheme -
Monthly Data Request Form

Practice Name:

Practice National Code:

Data provided is from the following month/year only:

Please select the Month:

Please select the Year:

Name and role of authorised individual submitting rebate form:
First Name

Last Name

Your Role:

FOR EACH INHALER PLEASE ENTER THE NUMBER "DISPENSED".

Easyhaler Budesonide 100mcg (200 dose) Packs Dispensed:

Easyhaler Budesonide 200mcg (200 dose) Packs Dispensed:

Easyhaler Budesonide 400mcg (100 dose) Packs Dispensed:

Easyhaler Beclometasone 200mcg (200 dose) Packs Dispensed:

Fobumix Easyhaler 80mcg/4.5mcg (120 dose) Packs Dispensed:

Fobumix Easyhaler 160mcg/4.5mcg (60 dose) Packs Dispensed:

Fobumix Easyhaler 160mcg/4.5mcg (120 dose) Packs Dispensed:

Fobumix Easyhaler 320mcg/9mcg (60 dose) Packs Dispensed:

Easyhaler Salbutamol 100mcg (200 dose) Packs Dispensed:

Easyhaler Salbutamol 200mcg (200 dose) Packs Dispensed:

Please be aware, all dispensing information submitted will be validated using practice prescribing and dispensing data processed by Safe Dispenser Ltd.

Thank you for supplying your Monthly Data for the Orion Pharma (UK) Limited Dispensing Doctor rebate scheme.

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Safe Dispenser Ltd, Norfolk Clinical Park, Rowan House, Buxton, Norwich, England, NR10 5RH, United Kingdom

Norfolk Clinical Park
Buxton, Norwich NR10 5RH

Orion Pharma UK LtdDispensing Doctor Rebate Scheme -Monthly Data Request Form

Orion Pharma UK Ltd
Dispensing Doctor Rebate Scheme -
Monthly Data Request Form