Prescriber Application Form To Prescribe Through Us

If you are prescribing practitioner, please complete the form below to be added to our database. We will then pass your detail on to non-prescribing practitioners in your area.

First Name *

Last Name *

Contact Number * Please enter the number you wish non-prescribing practitioners to contact you on.

Email Address

Profession *

Professional Registration Number *

Where are you based? * Please state county and town/city

Are you willing to prescribe in any other areas of the country? If so, where?

Which treatment(s) are you trained in? Please select all that apply

Botox
Dermal Filler
Microsclerotherapy

Are you happy to prescribe for; (please tick)

Nurses
Pharmacists
Professionals Allied to Medicine

What do you charge per prescription?

Do you have any requirements for arranging consultations? eg minimum number of patients, distance willing to travel etc

Are you happy for your data to be kept in a secure list which will only be accessed by Facethetics trained professional practitioners?

If No, how would you like our non-prescribing practitioners to receive your details? * (Please tick one)

Facethetics can supply my details only to non-prescribing practitioners who live in the same area as me
•Facethetics can provide me with details of non-prescribing practitioners in my area and I will contact them myself

Prescriber Form

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