General Information Company name (If individual insert full names) Trading name Company reg no. (If individual insert ID number) VAT number Social Media Handle Dr Affiliated YesNo Name of Physician Dr Practice number Frequency of Dr on site Physical, Shipping & Postal Address Physical Street Address Shipping Address (you may specify if same as above) Postal Address (you may specify if same as above) Postal Code (you may specify if same as above) Contact Information Owner (name & surname) Telephone (Mobile) Telephone (Landline) Email Accounts contact person (name and surname) Email (accounts deparment) We want to keep you updated Do you give consent to be added to the region-based broadcast Whatsapp group? (Only brand related information by your designated product specialist will be shared on this group) Yes Do you give consent to share latest news via our newsletter? Yes We want to connect you with clients Do you give consent to display your clinic/practice's name and location, as shared in this form, on our website? Yes Do you give consent to share your business' social media handle to potential customers via social media? Yes Online Store Product specialist explained the process of going online if I would like to do so in the future and I understand the procedure to follow. Yes Product Specialist Product specialist explained the process of going online if I would like to do so in the future and I understand the procedure to follow. ---Sera-Rose HarperUlrike SpiesKleoni VenterElle CurnowDourina Ritschewald
