JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Registration & Consent: Staying In Touch Email Campaign
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Please complete the once off registration and consent form below in order for us to automatically advertise these campaigns to your customers on behalf of your Pharmacy.
*
I hereby give consent. Let's get started!
Required
Your Name:
*
Your answer
Pharmacy Name:
*
Your answer
Pharmacy BHF / Practice Number:
*
Your answer
Pharmacy Contact Number:
*
Your answer
Pharmacy WhatsApp Number
Another way to communicate with your Patients. If you need assistance, contact us.
Your answer
Pharmacy Email Address:
*
Your answer
I'd like to do the following:
(Tick to Email to Patients)
(Tick to Post to Facebook)
(Tick to Post on WeCare Web Page)
Specify Pharmacy Delivery Information
*
Your answer
Trading Hours (Please specify in detail for all days of the week)
*
Your answer
Pharmacy Group Branding
None (Generic)
Pharmacy at SPAR
Alpha Pharm
Link Pharmacy
Arrie Nel Pharmacy
The Local Choice
Other:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
