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? *

Check the box of the model we currently support, If you have a model other than the ones listed then chose other and enter your model details, chose "send me a scanner" if you don't have any of these models. Freight to your area is included in the trial. The 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.

Enter your Scanner Model details

This is required when you pick other for scanner

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 *