Registration

Title * DrMrMrsMs

First Name *

Last Name *

Profession * Select a professionDoctorDentistIndependent Prescriber- PharmacistIndependent Nurse- Prescriber

Date of Birth *

Gender *MaleFemale

Unique Code to Approve Prescription
(min. six characters) Please choose a unique code that you will need to enter to approve prescriptions. Your code must be at least six characters long and consist only of alphanumeric or alphabetic characters. Keep this code safe, and do not share it with others. *

Registration Number *

Mobile Number *

Fax (optional)

Select Photo ID * Select a photo IDDriving LicencePassport

Upload File *

Select Proof of Address * Select a proof of addressPersonal Mobile BillUtility Bill

Upload File *

Upload Signature (.jpg, .jpeg, .png) *

Upload Insurance Certificate *

Upload Aesthetic Training Certificates Please upload all certificates (with expiry dates) in one go that you have. *

Enter Clinic Postcode or Street Name *

Clinic Address *

Enter Home Postcode or Street Name *

Home Address *