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.
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.
