Account Applications

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Account Application Form

All information submitted via this form will be treated as strictly confidential. Please complete all the required fields* in this form and press the submit button. Your application will be processed within 7 days.
Email Address(*)
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Date(*)
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Name of Applicant or Business
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Number and Street(*)
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City(*)
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State(*)
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Postcode(*)
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Country(*)
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Delivery Address(*)
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As Follows
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Phone(*)
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Fax(*)
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Directors Names(*)
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Type(*)
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ACN
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Therapeutics registration number
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Provider Number
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Business Established(*)
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Preferred Payment Option(*)
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Other
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Trade Reference 1(*)
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Phone 1(*)
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Trade Reference 2
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Phone 2
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Trade Reference 3
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Phone 3
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Expected Monthly Purchases(*)
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I/we agree to OptiMed's Terms and Conditions I/we hereby agree to pay all accounts on a strictly 30 days from invoice basis unless otherwise stated on the official invoice and in accordance with our standard terms and conditions. I/we understand that , should payment not be made according to these terms, the account facility will be revoked. I/we also agree that all the information contained within this application form is true. By submitting this form you agree to all these conditions. * To purchase certain licenced pharmaceuticals ( therapeutics in particular) you will be required to submit a copy of your registration certificate.
I agree to the terms and conditions(*)
Yes

Registration certificate
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Anti Spam Filter(*)
Anti Spam Filter
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