PRACTICE REGISTRATION APPLICATION [LD]

Your Details //
As the owner of the practice submitting this registration application.
PRACTICE NAME*
COMPANY NAME*
PRACTICE LOCATION*
YOUR TITLE*
YOUR FIRST NAME*
YOUR LAST NAME*
EMAIL ADDRESS TO RECEIVE COMMUNICATION FROM US*
example@example.com
PRACTICE OWNER MOBILE NUMBER - The number where we can reach you*
Registered / Licenced Medical PractitionerRegistered / Licenced Dental PractitionerRegistered / Licenced Healthcare PractitionerAesthetic TherapistOther
There seems to be an error in the answers you provided //

You indicate in this field that you are a registered Medical Practitioner, but the title "Dr." was not selected in the "Title of Practice Owner" field:
- If you are a Medical Practitioner, please correct your title field.
- If you are not a registered Medical Practitioner, please select another option for this question.
YesNo

Details of the person responsible for account-related inquiries //
USE PRACTICE OWNER DETAILS
TITLE*
FIRST NAME*
LAST NAME*
EMAIL ADDRESS OF ACCOUNTS DEPARTMENT*
example@example.com
PHONE NUMBER OF ACCOUNTS DEPARTMENT*
VAT NUMBER (if applicable)

Practice information //

PRACTICE PHYSICAL ADDRESS

This is the address where clients / patients can visit your practice.

Please be as accurate as possible.
STREET ADDRESS - Street number and name*
e.g.. 123 Main Street
BUILDING NAME (if applicable)
CITY NAME*
e.g. Pretoria
REGION / SUBURB*
e.g. Newlands
PROVINCE / STATE*
e.g. Gauteng
POSTAL / ZIP CODE*
e.g. 0031
COUNTRY*
PRACTICE PHONE NUMBER - The telephone number clients / patients can use to phone your practice*
PRACTICE WEBSITE (if applicable)
e.g. www.dermalhealthpractice.com

- Declaration and Signature // {autoPractitionertType}
  The declaration and signature below should be completed by the {autoPractitionerType} affiliated with your practice.
- By signing in the field below, you, as a Medical Practitioner registered with the Health Professions Council of South Africa (HPCSA), accept full responsibility for DERMEXCEL™ products dispensed at the practice stipulated in this application form.
- Signature of Medical Practitioner registered with the Health Professions Council of South Africa (HPCSA) who completed and/or reviewed this application form*
  
  Clear
- By signing in the field below, you, as a Dental Practitioner registered with the Health Professions Council of South Africa (HPCSA), accept full responsibility for DERMEXCEL™ products dispensed at the practice stipulated in this application form.
- Signature of Dental Practitioner registered with the Health Professions Council of South Africa (HPCSA) who completed and/or reviewed this application form*
  
  Clear
- By signing in the field below, you, as a Pharmacist registered with the South African Pharmacy Council (SAPC), accept full responsibility for DERMEXCEL™ products dispensed at the practice stipulated in this application form.
- Signature of Pharmacist registered with the South African Pharmacy Council (SAPC) who completed and/or reviewed this application form*
  
  Clear
- By signing in the field below, you, as a Professional Nurse registered with the South African Nursing Council (SANC), accept full responsibility for DERMEXCEL™ products dispensed at the practice stipulated in this application form.
- Signature of Professional Nurse registered with the South African Nursing Council (SANC) who completed and/or reviewed this application form*
  
  Clear
- By signing in the field below, you, as a Chiropractor registered with the Allied Health Professions Council of South Africa (AHPCSA), accept full responsibility for DERMEXCEL™ products dispensed at the practice stipulated in this application form.
- Signature of Chiropractor registered with the Allied Health Professions Council of South Africa (AHPCSA) who completed and/or reviewed this application form*
  
  Clear
- By signing in the field below, you, as a Registered / Licensed Medical / Health Care Practitioner, accept full responsibility for DERMEXCEL™ products dispensed at the practice stipulated in this application form.
- Signature of Registered / Licensed Medical / Health Care Practitioner who completed and/or reviewed this application form*
  
  Clear
- Signed by {autoPractitioner}
  Registration Number: {autoRegistrationNumber}
- Date signed
  
  MonthDayYear
- Declaration and Signature // Practice Owner
- I CONFIRM ALL THE INFORMATION I PROVIDED IN THIS FORM IS TRUE AND CORRECT
- Signature of Practice Owner*
  
  Clear
- Signed by {autoPractice}
  {companyName}
- Date signed
  
  MonthDayYear
- Should be Empty: