First Name *

Last Name *

Please upload your ID/ Passport **(Required)** *

What is your profession? * Aesthetic practitioner Beautician Doctor / Dentist Nurse Other

In order to verify your ID, please upload a recent image of your face (this cannot be an image of a document/ID)

Registration number if available (GMC, GDC, GPhC,...)

Do you want to register as a prescriber? (If yes, i confirm that i have all the necessary registrations, qualifications and indemnity insurance to legally cover all online patient consultations and prescribing activities) Yes No

If you're collaborating with a prescriber, please provide their email address.

Please upload your training certificate **(Required)** *

Please upload your toxins training certificate ( To unlock toxins on your account)

Please upload extra training certificate or insurance

Date of birth *

I confirm that i hold the necessary qualification(s) and indemnity insurance to purchase and administer all items that i purchase through www.wimpolepharmacy.co.uk and that all the information i have provided is true. *