PRACTICE REGISTRATION

YOUR DETAILS

As the owner of the practice submitting this registration application.

Trading name for patients / clients

Registered company name for invoices

e.g. example@example.com

Area CodePhone Number

The telephone number clients / patients can use to phone your practice

e.g. Dr. / Mr. / Mrs. / Sr.Your NameYour Last Name

The number where we will be able to reach you. This number will NOT be shared with clients / patients.

There seems to be an error in the answers you provided

You indicate on this field that you are a Medical Practitioner registered with the HPCSA, but the title "Dr." was not selected in the "Title of Practice Owner" field: If you are a Medical Practitioner registered with the HPCSA, please correct your title field.
If your profession is not one of these two options, please select "no" at the previous question.
If you are a a Medical Practitioner registered with the HPCSA, please select "no" at this question.

Please use the format: MP 1234567

There seems to be an error in the answers you provided

The MP number should start with MP for a Medical Practitioner or DP for Dental Practitioner.
If your profession is not one of these two options, please select "no" at the previous question.

General PractitionerDermatologistPlastic SurgeonOther

Aesthetic TherapistOther

e.g. General Medical Council in the UK

Please use the format: SANC 12345678

Please use the format: DT 1234567

Please use the format: P12345

Please use the format: CH 1234567

Please use this format: DP 1234567

Please use the format: PT 1234567

Please use the format: A12345

Yes, I would like to retail DermExcel at my practice.No, I would like to register as a Medical practitioner but only buy for myself, family and friends.

Medical Practitioner (with MP number)Dental Practitioner (with DP number)Registered Nurse (with SANC number)

Please use this format: MP 1234567

There seems to be an error in the answers you provided

The MP number should start with the letters "MP"
If the Practitioner at your practice is not a Medical Practitioner, please change your answer in the "profession" field

Please use this format: DP 1234567

Please use the format: SANC 12345678

First Name of PractitionerLast Name of Practitioner

Telephone nr. / Mobile nr. of Medical Practitioner

Browse Files to upload

Details of person responsible for account related enquiries:

USE THE PRACTICE OWNER DETAILS I SUPPLIED AT THE START OF THIS FORM

e.g. Dr. / Mr. / Mrs. / Sr.Your NameYour Last Name

Contact Person at the Accounts Department:

Phone number for account related enquiries

accounts@example.com

Practice information:

PRACTICE PHYSICAL ADDRESS

This is the address where clients / patients can visit your practice. Please be as accurate as possible.

Street Address

Region

CityProvince

Postal CodeCountry

e.g. 167 Main street

e.g. Menlyn Square Office Park, Block D, Ground floor

Please note that only the Medical Practitioner in affiliation with your practice should sign below.

Please note that only the Health Care Practitioner in affiliation with your practice should sign below.

Medical Practitioner

Medical Practitioner affiliated with this practice

Dental Practitioner affiliated with this practice

Registered Nurse affiliated with this practice

Registered Dietician affiliated with this practice

Registered Pharmacist affiliated with this practice

Registered Podiatrist affiliated with this practice

Registered Chiropractor affiliated with this practice

Registered Physiotherapist affiliated with this 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.

By signing in the field below, as a Dental Practitioner registered with the South African Pharmacy Council (SAPC), you accept full responsibility for DermExcel products dispensed at the practice stipulated in this application form.

By signing in the field below, you, as a Professional Nurse registered with the South African Nursing Council, accept full responsibility for DermExcel products dispensed at the practice stipulated in this application form.

By signing in the field below, you, as a Chiropractor registered with the Chiropractic Association of South Africa, accept full responsibility for DermExcel products dispensed at the practice stipulated in this application form.

By signing in the field below, you, as a Physiotherapist 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.

By signing in the field below, you, as a Podiatrist 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.

By signing in the field below, you, as a Dietician 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.

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.