Business Registration Form

Business Registration Form
Business Registration Form - Terms and Conditions

Thank you for joining our Employee Health Program This program ensure that your employees' health needs are supported through your business.
Your employees will benefit from:
1. An initial Doctor's consultation, free of cost to your employee and your company.
2. 10% Discount on all prescription and over the counter medications, as well as cosmetics and other related purchased from our sister companies. A discount card must be purchased by each employee at the cost of $500 to benefit from these discounts.
3. Regular health tips and information, as well as special offers from time to time.
4. Virtual or in person follow up visits with the attending physician, at a cost of $3,000 per visit.
5. Support in their journey towards being healthy in the workplace, through activities and initiatives which Pharma X will organize and host.
Procedure:
1. Fill out the form and submit.
2. Our team will contact your employee or the contact person indicated to schedule an initial consultation.
3. Future consultations must be booked and paid for before the start of the consultation. This can be done in person at our clinic or through MMG to Pharma-X Consultancy Inc. MMG Number : m516588
4. If your employees exceed the number of fields provided below, kinly use the link again to fill a new form with the additional employee information.
Thank You!
Business Name*
Number of Employees*
Nature of Business*
Contact Person*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.
Business Email*
example@example.com
How many employees do you have?
Employee Name

First NameLast Name
Employee Phone
Please enter a valid phone number.
Employee Email
example@example.com
Employee Name

First NameLast Name
Employee Phone
Please enter a valid phone number.
Employee Email
example@example.com
Employee Name

First NameLast Name
Employee Phone
Please enter a valid phone number.
Employee Email
example@example.com
Employee Name

First NameLast Name
Employee Phone
Please enter a valid phone number.
Employee Email
example@example.com
Would you like to subscribe to our email list to receive special offers from our pharmacy?*

YesNo
I agree to the terms and conditions of this for and to pay the cost of $300 per employee to receive a Sign Up Card, which they can use to access 10% discount on all prescription drugs, over the counter medications, cosmetics and other purchases from our sister companies.

Agree
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Business Registration Form

Business Registration Form - Terms and Conditions