EPP Prescriber Onboarding

EPP Prescriber Registration Form

NOTE:

Your IP Address and location details are captured as part of this submission. Your IP Location: 52.14.148.63
You agree for us to hold this information as part of this submission. We require this for security and legal purposes.

Todays Date

Clinic Information

Clinic Name

Clinic Address

Street Address

City

Province

Postal Code

Country

Prescriber(s) Information

First

Last

Qualification

Email Address

Your company / social profile website link:

Phone

4 Digit Pin

Prescriber's Reg Number Type

Prescriber's Reg Number

Address of Recipient

Street Address

City

State / Province

Post Code

Country

Documents

Passport / Photo ID Scanned

File Upload

Signature Image (for PDF)

File Upload

Proof of Address (Utility Bill or Council Tax)

File Upload

Any other information

I consent to have eHealth Solutions Ltd. use my submitted information to process my registration. I understand that I can request the deletion of my data under the GDPR guidelines if needed. And that I shall need to attend a video call where I will be required to have a conversation with my camera turned on.

I confirm that all provided details are accurate to the best of my knowledge. I take full responsibility for any misrepresented information and acknowledge that providing false information may lead to legal consequences, including potential liability for fraud or identity theft.

I accept

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I have read and agree to the Terms and Conditions and Privacy Policy

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