New Pharmacy Registration Form

This form should only be used to register NEW pharmacies. If you have purchased an existing pharmacy, please use the Contact Us form.

Instructions

Primary Contact Details

AHPRA Number

First Name

Last Name

Contact Preferred Name

Mobile Phone

Is the contact person the owner

NoYes

Your Pharmacy Details

Pharmacy Name

ABN

Business/Landline Phone

Fax Number

Primary Email Address

Invoices, newsletters and other communications will be sent here unless otherwise specified.

Invoice Email

Should you wish invoices to go to an alternate email address to the one provided as the primary pharmacy email address, please enter it here.

Head Office Email Address

If you have a contact at head office we should be directing communications to please record here.

Your Pharmacy Address Details

Street 1 Address

Street 2 Address

State

Postcode

Suburb

Your Pharmacy Postal Address Details

Is the same as pharmacy address

NoYes

Postal Street 1 Address

Postal Street 2 Address

Postal State

Postal Postcode

Postal Suburb

Your Pharmacy Additional Details

PBS Approval Number

Date Approval Issued

Is the pharmacy ready to be assessed now?

NoYes

it may take up to 3 months for an assessment date to become available from date of request.

Preferred From Date

Preferred To Date

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New Pharmacy Registration Form

Primary Contact Details

Your Pharmacy Details

Your Pharmacy Address Details

Your Pharmacy Postal Address Details

Your Pharmacy Additional Details

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