PRACTITIONER REGISTRATION FORM

Your Detail

Title*
Email Address*
First Name*
Last Name*

Password

Password*
Confirm Password*

Clinic/Business Information

Name of the Clinic/Business*
Business Type*
Business Number (ABN/NZBN)*
Primary Profession*
Association Number*
Association Name*
Qualification

Please assist us in the approval process by uploading a scanned copy of Certification/Association relavent to your modality:

Only accept .pdf .jpg .png .jpeg file (20 MB Max):

Business Address

Street Address*
Suburb*
State/Region*
Country*
Post Code*
Telephone*
Mobile Phone*
Fax

Credit Application


I/We would like to apply for a credit account:
 Yes     No
Are you the registered owner of the business?
 Yes     No

We will require authorisation from the business owner to proceed with credit account set-up.

Have any of the individuals above been declared Bankrupt?
 Yes     No
Has the business ever been refused credit?
 Yes     No

Credit Application Declaration
I/We hereby apply for credit with Medlab Clinical Limited and certify that the information supplied in this application is true and correct. I/We authorise Medlab Clinical Limited to conduct a Credit History Check with an external Credit Agency. I/We understand that all information will be treated as confidential and will not be supplied to any other organisation.

Patient Billing


If you do not have a dispensary and are interested in patient billing, a Medlab Practitioner consultant will be in contact with you.

I would like to set-up a patient billing account:
 Yes     No

Terms For Use of Website


I / We have read and agree to the Terms and Conditions, Terms of Sale and the Medlab Privacy Policy displayed on the Medlab website. I / We agree to comply with and be bound by these policy documents (which may be amended or updated from time to time).

Should you have any enquires on Medlab Clinical Pty Ltd Terms and Conditions, Terms of Sale or Privacy Policy please contact: hello@medlab.co or call 1300 369 570.

By clicking on the the submit, you Agree to the Terms and Conditions, Terms of Sale & Medlab's Privacy Policy.

Please check to agree to our Terms & Conditions.