IUMP – Register

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REGISTRATION FORM

Please complete all required fields in this form. Once your form has been submitted, your account will be verified and a confirmation email will be sent to you.

*Username

*Email

*First Name

*Last Name

Website

*Password

*Confirm Password

*Pharmacy Name

*RAMS Number

*Y Number

*ICPA Number

*Owner Name

*Owner Surname

*Owner Personal Email

*Owner Personal Mobile

*Address 1

Address 2

*Suburb

*City / Town

*Postal Code

*ProvinceEastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorthern CapeNorth WestWestern Cape

*Company Registration Number

*VAT Number

*Trading Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Public Holidays

*Pharmacy Contact Number

Pharmacy Fax Number

*Pharmacy Email Address

*Clinic ServicesYesNo

Clinic Trading Hours

Clinic Services Offered

Blood Pressure

Blood Glucose

Cholesterol

Lipogram

HBA1C Testing

BMI

Vaccinations & Immunisations (adults)

Mother & Baby services

Woman's Health

Smoking cessation

HIV Pre & Post counselling

Family Planning

Wound Care

*Clinic Nurse

Yes

No

Nurse Name

Nurse Surname

Nurse's Email Address

Nurse Mobile Number

*Do you offer Pathology Lab services

Yes

No

Name/s of Pathology Lab service provider

*After-Hours Service

Yes

No

Do you offer an after-hours service?

After-Hours TelContact number for after-hours

*Home Deliveries

Yes

No

*Pharmacy Loyalty Programme

Yes

No

Describe your Loyalty Programme

*RP Name

*RP Surname

*RP Email Address

*RP Mobile Number

*RP P-Number

Accept our Terms & Conditions

*

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