Prescriber Form Name * Last * Phone Email * Professional Registration Number Profession * Where are you based? * Are you able to prescribe in any other areas of the country? If so, where? Are you happy to prescribe for; * Medic Non Medic Please tick What do you charge per prescription? Do you have any requirements for arranging consultations? eg minimum number of patients, distance willing to travel etc Do you have any comments or questions? * *Please confirm that you authorise us to keep your information securely. This information will only be passed from us to professionals who have trained at TABA UK Submit
