Script Capture Trial

Pharmacy Details

Pharmacy Name *

Your Chemist POS Customer Number

Contact Person *

Phone Number

Email *

Your Dispense Software *

Address *

Address Line 1

City

State / Province / Region

Postal Code

ScriptCapture Details

Number of scripts processed per day (Average) *

Nominate the Workstation (S) for ScriptCapture *

Email address to use with ScriptCapture *

Already have a scanner? *

Brother ADS-2800
Fujitsu ScanSnap iX1500
Fujitsu ScanSnap iX500
Send me a Scanner

Check the box of the model we currently support, chose "send me a scanner" if you don't have any of these models. Freight to your area is included in the trial. Scanner will be invoiced on completion of the 30 day trial if you proceed with the service. Should you wish to cancel, please send the scanner back in its original packaging to the CPD warehouse.

Terms & Conditions *

I have read and agree to the Terms of Service

This service will auto-renew after the 30 day trial unless cancelled prior to the end of your monthly trial.

Signee Name *

Date *

Signature *

Name