Bio-Alai Account Application

Bio-Alai Account Application
Thank you for your interest in becoming an authorized Bio-Alai® provider. To qualify as a provider you must be a doctor, nurse, psychologist, allied health practitioner or dermal clinician with relevant registration and training. If you meet the criteria, please fill in the form below and on completion of our review we will email a link to set up your password for our providers portal.

We are committed to improving outcomes for aesthetic patients by supporting clinicians with education and partnering with clinics to bring streamlined, individualised solutions and premium formulations to the aesthetic industry.

When you register as a Bio-Alai® provider, you and your team will have access to the Provider Portal where you will find educational content, webinar recordings, training modules, clinic tools, marketing resources and our on-line ordering gateway.
PRACTITIONER TYPE
Choose All that Apply*

Cosmetic PhysicianDermatologistPlastic SurgeonCosmetic NurseRegistered NurseNurse PractitionerEnrolled NurseGeneral PractitionerDermal ClinicianIntegrative / Functional MedicineDietitianPhysiotherapistNaturopathMyotherapistNutritionistChiropractorOccupational therapistExercise PhysiologistMedical SpecialistOther
BUSINESS DETAILS:
Business Structure*
if a Company - ABN / ACN
Trading Name*
Billing / Delivery Address:*

Street Address

Street Address Line 2

CityState

Post Code
Phone Number*
Please enter a valid phone number.
Primary / Accounts Email Address*
example@example.com
Bank Details (These details are needed for any future refunds and commission)*
Bank Name
BSB*
Account Number*
CERTIFICATION:
I hereby certify that I am a health professional*
Profession
Phone Number*
Please enter a valid phone number.
Name of Professional Body*
Membership No:
Declaration*
First Name Last Name*

First NameLast Name
Date*

DayMonthYear
Date
Signature*

Clear
Should be Empty:

Bio-Alai Account Application

PRACTITIONER TYPE

BUSINESS DETAILS:

CERTIFICATION: