Personal Details

First Name *

Last Name

Email *

Password

Confirm password

Business Details

Company/clinic name *

Company type *

Other company type

Company Registration No. *

VAT Registration No. *

Is your company already registered with Healthxchange Ireland?

Invoice/billing Address

Address line 1 *

Address line 2

City or Postal Town *

County *

Postcode

Country *

Phone number

Shipping Address

Shipping Address line 1 *

Shipping Address line 2 *

Shipping City or Postal Town *

Shipping County *

Shipping Postcode

Shipping Country *

Shipping Phone number

Are you a registered medical professional? *

Prescriber Profession *

Prescriber Registration No. *

Prescriber Photo ID *

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-74612-file2-1_

Prescriber Name *

Prescriber Email *

Prescriber Salutation

Prescriber phone number *

By submitting this form I confirm that I am authorised by the Company to enter such agreements. I confirm the Prescriber is an authorised signatory on this account and the information contained herein is correct. I have read the Privacy Statement and accept your Terms and Conditions available on your website www.healthxchange.ie *

After you submit this form, you will have the option to add a prescriber to your account. If you intend to do this please tell us the name of the additional prescriber below.

Additional Prescriber Name

By signing this form I confirm that I am authorised by the Company to enter such agreements; I confirm the account information contained herein is correct. I have read the Privacy Statement and accept your Terms and Conditions available on your website www.healthxchange.ie *

Thank you for registering your account.

Your application will now be processed by our team and you will receive further notification when you account is approved. This normally takes 1-2 business days.

If you would also like to register an additional prescriber on your account please click here.

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