Registration - Purchaser

Clinic Details

Basic Details

Clinic Name / Establishment Name

Company Name

Company Registration Number

Clinic Registration No (CKAPS)

Commencement Year

Operating Hours

Operating Days per Week

Clinic Owner (Pemegang Perakuan Pendaftaran in Borang B/F)

Type of Practice

General Practice - Please specify if have any specialisation

MEDICAL DEVICES POCT (Point of Care Testing)

TEST KIT POCT (Point of Care Testing)

Shipping Address

(Must be same with Borang B or Borang F)

Address 1

Address 2

Address 3

Postcode

City

State

District

Person in Charge Details

Full Name

NRIC (New Format)

E.g. 123456789123 (no dashes)

Gender

Male

Female

Full MMC Registration Number

Current APC No

Phone (Landline)

+6

E.g. 0x-1234 567 or 0x-1234 5678

Phone (Mobile)

+6

E.g. in 01x-1234 5678 or 01x-1234 56789

Fax (Office)

+6

E.g. 0x-1234 567 or 0x-1234 5678

Email Address

Please enter a common / group email address that's used by your organisation (e.g. info@abc.com.my)

Password

Eight characters minimum One lowercase letter One uppercase letter One number One special character

Please use a strong password.

Confirm Password

You need to enter your password again to confirm

Electronic Health Records

Does the clinic use clinical information/management system?

Yes

No

Document Upload

Certificate of registration to operate private medical clinic (Borang B or Borang F)

Maximum file size: 5MB

Only allow PDF, DOCX, XLSX, PNG or JPG.

MMC full registration certificate of person-in-charge

Maximum file size: 5MB

Only allow PDF, DOCX, XLSX, PNG or JPG.

Current annual practising certificate (APC) of person-in-charge

Maximum file size: 5MB

Only allow PDF, DOCX, XLSX, PNG or JPG.

Checkboxes

I confirm that the following facilities are available in the clinic computer, telephone, internet, printer, scanner, and fax machine.

Checkboxes

I declare that the information I have given on this form is true and complete and that I have not been convicted or found guilty of any criminal offence in any country.

Checkboxes

I accept and agree to be bound by the ebizMedic Terms of Service and Privacy Policy.

Signature

Clear

Please enter the verification code below

Purchaser Registration Form

Clinic Details

Basic Details

Shipping Address

Person in Charge Details

Electronic Health Records

Electronic Health Records

Document Upload

COMPANY

Customer Service

Payment Method

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Devices

Test Kits

Disposables

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Purchaser Registration Form

Clinic Details

Basic Details

Shipping Address

Person in Charge Details

Electronic Health Records

Electronic Health Records

Document Upload

COMPANY

Customer Service

Payment Method

Follow Us

Newsletter

SHOP BY PRODUCT

Devices

Test Kits

Disposables

Accessiblity

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