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

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Monday-Friday :
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General: admin@tabauk.com
Sales: sales@tabauk.com
Models Bookings: models@tabauk.com
0151 345 6597
Unit 7, Venture Point, Chester CH2 4NE

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