Prescriber Onboarding Form

Prescriber Details

First Name

Last Name

House/ Flat

Address Line 1

Address Line 2 (optional)

Town (optional)

Postcode

Phone

Four digit PIN ⓘ

Clinic Information

Clinic name and address (if applicable)

House/ Flat

Address Line 1

Address Line 2 (optional)

Town (optional)

Postcode

Upload Supporting Documents

Photographic ID (UK Passport/ Driving License)

Copy of your handwritten signature

Certificate of training: Injecting Dermal Fillers / Skin Boosters

Certificate of training: Injecting Botulinum toxins

Professional aesthetics insurance

Professional prescribing indemnity insurance

Registration Information

Registration Type

Registration Number

Consent

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

I consent to allow Dam Pharmacy to use my submitted information for processing my registration. I understand that, under GDPR guidelines, I can request the deletion of my data if necessary.

Signature Signature