Prescriber Onboarding Form

Clinic Information

Clinic Name

Clinic Address Line 1

Clinic Address Line 2

Clinic Town

Clinic County

Clinic Post Code

Prescriber Details

Prescriber First Name

Prescriber Last Name

Prescriber Address Line 1

Prescriber Address Line 2

Prescriber Town

Prescriber County

Prescriber Post Code

Job Title

Company Name / Profile

Phone

4 Digit Pin

Document Uploads

Passport / Photo ID

Signature Image

Proof of Address

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 Health 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

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Prescriber Onboarding Form