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Thanks a bunch for trusting us with your business. It means a lot to us, just like you do! We really appreciate your allowing us to partner with you.
Kindly fill out your practice setup details below:
Practice name
*
Degree(s)
*
(eg MB.ChB.(UCT))
HPCSA No.
*
PCNS (Practice) No.
*
VAT no. (If applicable)
Physical address
*
Postal address
*
Email address
*
Tel no. (Landline/Mobile)
*
Fax no. (If applicable)
Your full name
*
Authorisation
*
I am authorised to act on behalf of the practice
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