Practitioner Account application form


Please ensure your name, address and especially email address are correct so that we can confirm we've received your application form. Fields marked * must be filled in.

Name
Company name and postal address
Contact information
Purchase method
Stock-onlyPersonalised Referral CodeBoth
** This code is exclusive to you and enables your clients to get 20% discount when they order, while earning you 20% referral bonus. The default code is your initial plus surname.
About you
We provide practitioners with literature to supply clients (subject to availability). If you'd like to receive leaflets, please indicate which of our products you are likely to recommend and we will endeavour to send you the relevant materials, along with stickers displaying your unique discount code.

Please tell us your general areas of interest (you may select multiple interests)
Bank details for commission payment via BACS

Declaration
I have read and accept Igennus Healthcare Nutrition's terms and conditions * Accept

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