PRACTICE REGISTRATION

*true

truefalse
*false

truefalse
Internal Email
example@example.com
#email sender
YOUR DETAILS

As the practice owner submitting this registration application.
PRACTICE NAME*
Trading name for patients / clients
EMAIL ADDRESS TO RECEIVE COMMUNICATION FROM US*
e.g. example@example.com
TITLE OF PRACTICE OWNER*
#valid title for mp

truefalse
Name of the practice owner*

First NameLast Name
#practice owner full name
Practice Phone Number: The telephone number clients / patients can use to phone your practice*
Owner Phone Number: The number where we can reach you*
Practice Phone Number: The telephone number clients / patients can use to phone your practice*
The number where we will be able to reach you. This number will NOT be shared with clients / patients.
OWNER MOBILE NUMBER - The number where we can reach you*
The number where we will be able to reach you. This number will NOT be shared with clients / patients.
#practice phone [final value]
#owner phone [final value]
location
south africa

South Africa
#national / international

NationalInternational
#geolocation data

	Practice Information
Practice Name
Email address
Practice tel nr.
Owner Name
Owner Profession
Owner tel. nr.
Internal / External Practitioner
Practitioner Name
Practitioner Profession
Practitioner tel. nr.
Professional Number
Practice Address
Accounts Contact Person
Accounts Email
Business Name
Accounts tel. nr.
VAT number
Preliminary approval status