Controlled professional access

Apply as a medical practitioner.

Submit your professional and practice details for verification. This application does not confer prescribing, procurement or dispensing authority.

South African practitioners only
Medical and Dental Professions Board
Review subject to documentary verification

Professional application

Practitioner verification

Fields marked * are required. Do not submit patient information in this form.

1. Practitioner

Identity and registration

First name *

Surname *

Professional email *

Mobile number *

HPCSA registration number *Medical practitioner registration will be checked.

Years in practice

2. Practice

Professional setting

Practice or facility name *

BHF / PCNS practice number

Province *

Dispensing licence *A prescription alone does not authorise a practitioner to dispense.

Dispensing licence numberComplete if you selected that you hold a current licence. Documentary proof may be requested.

3. Professional interest

Select all that apply

Peptide therapeutics Co-enzyme therapies, including NAD Product-specific clinical education Professional supply account

Additional professional context0 / 1800

4. Declarations

Required

I declare that the professional details supplied are true and current; that I am in good standing with the relevant authority; and that I will act only within my lawful scope, prescribing authority, dispensing authority and all product-specific regulatory conditions. * I have read the privacy notice and consent to verification of my professional details and contact about this application. *

Submitting does not guarantee approval, create a supply agreement, authorise access to any product or add you to general marketing. Verification records are handled for the purposes described in the privacy notice.