Dr. Adams Pharmacy

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Address

Professional Details

First Name *

Last Name *

Email Address *

Phone Number *

+44

Password *

Confirm Password *

Company Name

Address Street *

City / Town *

Province / State

Postal or Zip Code *

Country *

VAT Number

I am a registered prescriber

I am a non-prescribing aesthetic practitioner

Profession *

Profession Registration Council *

Profession Registration Number *

Pin (Create a personal 6-digit PIN to authorise prescriptions.) *

Signature *

Upload Passport / Driver's license / other governement-issued Photo ID *

Upload insurance document (Please submit the full aesthetic insurance document in PDF format, partial images or screenshots are not accepted.)*

Insurance document expiry date *

Upload Your Aesthetic Training Certificates (Multiple files are accepted.) *

Upload Your Toxin Training Certificate

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