Pharmacy Registration Form

Complete the form to sign up.

|
Title*
Title*
|
First Name*
First Name*
|
Last Name*
Last Name*
|
Email*
Email*
|
Professional Address*
Professional Address*
|
Postcode*
Postcode*
|
Birthday*
Birthday*
Eg: 01/02/1990
|
Phone*
Phone*

I am a prescribing professional (yes/no):
|
Select*
Select*
(If no) Please provide prescribers details. Include name, email, registered body and number if known
|
I am applying for
Non-surgical aesthetics
Weight loss treatments
Non-surgical aesthetics and weight loss treat
|
Registered body*
Registered body*
|
Registration Number
Registration Number
|
Registration Expiry*
Registration Expiry*
Eg: 01/02/2028

Required documents:

Upload your ID (passport or driving license):

Upload your insurance documents to us:

Upload your proof of Certificates (i.e. botulinum toxin or dermal filler injectables) to us

Upload your proof of completed injectable weight-loss product training to us: 

Please choose your desired password:
|
Password*
Password*
|
Password Again*
Password Again*