New Account Signup About The PharmacyAccount NumberPharmacy Name(Required)Store Manager / Key Staff Member(Required) First Name Last Name Store Address(Required) Street Address Suburb State Post Code Store Phone Number(Required)Store Email Address(Required) Group(Required)IndependentIPA: AllianceIPA: AdvantageIPA: Chemist Discount CentreIPA: Pharmacy CatalystTerry White ChemmartBlooms The ChemistPricelinePharmacy 4 LessAmcalChemist WarehouseDiscount Drug StoreGood Price PharmacyRamsay Health PharmacyOptimal PharmacyCapital ChemistGuardianNational PharmaciesUnited Discount ChemistsMy ChemistPharmaSaveCincotta Discount ChemistPharmacy777Other (List Below)Other GroupDo you offer sleep apnoea testing in store?(Required) No Sleep Testing Yes – Level 2 Testing Yes – Level 3 Testing Yes – Level 4 Testing Do you offer sleep apnoea treatment in store?(Required) No Sleep Treatment Yes – APSS Yes – BOC Yes – Direct Account Other Which brands do you stock?(Required)Select all that apply. ResMed Lowenstein Fisher & Paykel BMC Philips Sefam SnoreRX HUSHD Business DetailsLegal Entity ABN(Required)Entity TypeLegal Entity NameOwner First Name(Required)Owner Middle Name(s)Owner Last Name(Required)Owner Mobile Number(Required)Owner Email Address (Agreement Will Be Sent Here)(Required) We will need to grab some more information from you after checking your entity details.Please fill the contact details below and finish submitting the form.Contact Name(Required)Mobile Number(Required)Contact Email(Required) How many directors are in this company?(Required)1 Director2 Directors3 Directors4 Directors5 Directors6 Directors7 Directors8 Directors9 Directors10 DirectorsList All Directors Director First Name Director Last Name Director Mobile Director Personal Email Authorise Agreement Actions Edit Delete There are no Directors. Add Director Maximum number of directors reached. Who is the contact person responsible for filling in this form?(Required) A Director Listed Above Someone else? Add Them Below Select Contact From Director List(Required)– No Results –Add New Contact Responsible For Filling In This Form (If Not An Owner/Director Listed Above)Contact Name(Required) First Last Role(Required) Owner / Proprietor Pharmacist Manager Marketing Contact Email Address(Required) Contact Phone(Required) Proudly powering the EasySleep program.
