Medical Provider Application Form

Medical Provider Application Form

Medical provider application form Please complete this form in BLOCK CAPITALS. Please send your completed application form to Now Health International (Europe) Limited, Suite G3/4, Building Three, Watchmoor Park, Camberley, Surrey, GU15 3YL, United Kingdom. You can also scan and email it to [email protected] or fax it to +44 (0) 1276 602120. Section 1: Medical facility details 1.1 Full name of medical facility: 1.2 Registered address: 1.3 Website address: 1.4 Type of medical facility: Section 2: Medical provider relationship details 2.1 Responsible person for application: First name(s): Family name: What do you like to be called? (If your full name is John Andrew Smith, you might like to be called John or Mr Smith or Andy. We will address all correspondence to you in this way.) 2.2 Telephone: 2.3 Fax: 2.4 Email: Section 3: Medical provider contact details 3.1 Contact person for future business operation (if different from Section 2) First name(s): Family name: What do you like to be called? (If your full name is John Andrew Smith, you might like to be called John or Mr Smith or Andy. We will address all correspondence to you in this way.) 3.2 Telephone: 3.3 Fax: 3.4 Email: Section 4: Declaration We declare that answers and statements given in this application are accurate to the best of our knowledge and undertake to inform Now Health International (Europe) Limited of any material change of circumstances promptly. Signature: Date (dd/mm/yyyy): / / Now Health International (Europe) Limited is authorised and regulated by the Financial Conduct Authority. Now Health International (Europe) Limited, Registered Office: Suite G3/4, Building Three, Watchmoor Park, Camberley, Surrey, GU15 3YL, United Kingdom. Registered in England No. 7121668. WC EUR 28026 01/2018.

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