Patient Ordering - Practitioners Account Upgrade Form

It's been in the works for a while, and now, ProHerb has online product prescribing for practitioners!
If you hold an account, and would like to be able to precribe products to your patients (or general customers), and give them access to self-service ordering, please complete the form below, and we will upgrade your account you so can start prescribing, and reduce your administrative management of patient scripts (and orders).

Upgrade Your Account - Patient Ordering Access

* Indicates required field

YOUR ACCOUNT NAME: *

Account Holder Details:

Account Holder First Name *

Account Holder Last Name *

Account Email *

Conditions of Access:

Prescriptions placed via our Patient ordering app, are the sole responsibility of the prescribing practitioner.
Patients are able to securely order directly through the app based on the prescribed products for the patient, at the prices and quantities set by the prescribing practitioner.
Accumulated credit from fulfilled Patient Orders, can be credited to your primary purchasing account, or paid to a nominated bank account at the end of the following month if there are no outstanding payments on your primary purchasing account.
Some products may not be visible online. Please consult your Practitioner Consultant to review your purchasing & prescribing permissions.

Your Declaration:

BY SUBMITTING THIS FORM, I CONFIRM THAT AS THE PRESCRIBING PRACTITIONER,

I AGREE TO THE PROHERB POLICIES, TERMS & CONDITIONS, AND CAN CONFIRM THAT THE INFORMATION SUPPLIED IS ACCURATE & TRUE. I ALSO CONFIRM THAT I ACCEPT RESPONSIBILITY FOR THE PRESCRIPTIONS I SET WITHIN THE APP FOR MY PATIENTS, AND THAT I WILL NOT GIVE OUT MY LOGIN DETAILS. *

I AGREE

Upgrade my Account!

PATIENT ORDERING​REQUEST ACCESS

Patient Ordering - Practitioners Account Upgrade Form

Upgrade Your Account - Patient Ordering Access

Account Holder Details:

Conditions of Access:

Your Declaration:

PATIENT ORDERING
REQUEST ACCESS