Your Details //As the owner of the practice submitting this registration application.
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:
Details of the Practitioner //
Details of the person responsible for account-related inquiries //
Practice information //
PRACTICE PHYSICAL ADDRESS
This is the address where clients / patients can visit your practice.
Please be as accurate as possible.
Declaration and Signature // {autoPractitionertType}The declaration and signature below should be completed by the {autoPractitionerType} affiliated with your practice.
Signed by {autoPractitioner}Registration Number: {autoRegistrationNumber}
Declaration and Signature // Practice Owner
Signed by {autoPractice}{companyName}