B2B Portal Registration Form

B2B Portal Registration Form

Required to create B2B Portal account
Name*

First NameLast Name
Pharmacy*
Pharmacy address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ABN*
AHPRA number*
Email*
example@example.com
Phone Number*

Area CodePhone Number
How did you hear about SWAYNE Orders?
1. Complete form and submit

2. You will be directed to complete the Distribution Supply Agreement

3. Receive email invite to B2B Portal

4. Create first order

5. View invoice in B2B portal

6. Pay within 14 days of order date
Should be Empty: