Email Address
Password
Register your Practise
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Register Your Practice // PLUS
Your Desired Login Details
Email Address
Must be valid. Will be used as your username to login to the site
Repeat Email Address
Your Practice's Details
Entity Name
Contact Name
Contact Surname
Personal Website
Company Reg Number
Vat Number
Practice Number
Physical Address
Postal Address
Phone Number
Working Eye Care Pro
HPCSA Number
Where did you hear about us?
Doctors Belonging to Practice
Doctor
1
Doctor's Name
Doctor's Surname
Doctor's Email Address
Type of Doctor
Please select
Optometrist
Opthalmologist
Additional R100 / month
Your Payment Details
Account Holder
Bank
Account Number
Branch Code
Account Type
Direct Debit Day
Choose
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By clicking the 'Join' button below, you assure that you have read and agree to the
Terms & Conditions
.
Additionally you agree that this form constitutes a formal binding agreement to to debit your account once off with
R250.00
.
