Registration – Medmart Health

Full Name of Practitioner *

Medical Practice Number (HPCSA/Practice No.) *

Professional Designation *

Specialization (if applicable)

Practice Name

Physical Address

City/Town

Province

Practice Contact Number

Practice Email Address *

Preferred Contact Method

Estimated Monthly Procurement Value (R)

Do you require bulk order quotes or prefer direct online ordering? *

How often do you place orders? *

VAT Registration Number (if applicable)

CSD Registration Number (if applicable)

BEE Level (if applicable)

Would you like a Medmart representative to call you to assist with your setup or requirements?

Any special product requests or notes?

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I confirm that the information provided above is accurate and that I am authorised to act on behalf of the above-mentioned practice. *

I consent to receive Medmart Health's product updates, quotes, and promotional offers. *

I understand Medmart Health is BEE Level 1, SAHPRA registered (application in progress), and compliant with national procurement standards. *

Username *

User Password *

Confirm Password *

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