ScriptEase EPP Registration

ScriptEase EPP Prescriber Registration Form

Note:

Your IP Address and location details are captured as part of this submission. Your IP Location: 216.73.216.26
You agree for us to hold this information as part of this submission. We require this for security and legal purposes.

Clinic Information

Clinic Name

Clinic Address

Street Address

City

Province

Postal Code

Country

Prescriber(s) Information

First

Last

Qualification

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 accept

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I consent to have GlucoRx and eHealth Solutions store my submitted information, so they can process my registration and, if needed I can request to delete my data on request under the GDPR guidelines.

I have read and agree to the ePrivate Prescriptions system Terms and Conditions and Privacy Policy

I accept the GlucoRx Privacy Policy. I consent to have GlucoRx and eHealth Solutions store my submitted information, so they can process my registration and, if needed I can request to delete my data on request under the GDPR guidelines.