New customers

Account Application Form

Complete the form below to apply for a trade account. It takes around five minutes. Fields marked * are required.

1. Business details

Tell us about the business opening the account.

Trading name *

Registered / legal company name *

Business type *

Legal entity *

Company registration no. (if applicable)

VAT number (optional)

Years trading (optional)

Website (optional)

2. Addresses

Registered / invoice address *

Postcode *

Country *

Delivery address is the same as the invoice address

3. Contacts

Main contact name *

Position *

Email *

Telephone *

Accounts contact (if different)

Accounts / invoice email (optional)

Superintendent pharmacist / Responsible Person

GPhC / professional registration no.

4. Licences & registration

Provide whichever apply to your business. We verify all licences before supplying.

GPhC premises registration no.

ODS (F) code

WDA(H) licence no.

Home Office CD licence no.

Other licences / overseas authorisations

5. Trading

Estimated monthly spend

Account type

Products / categories of interest

How did you hear about us?

Additional information

6. Declaration I confirm the information provided is accurate and that I am authorised to apply on behalf of the business. * I consent to Islestone Pharmaceuticals verifying our licences and registrations and carrying out credit checks where a credit account is requested. *

Your details are used only to assess and manage your account application and are handled in line with UK GDPR.

Account Application Form

Application received