Account Registration Basic – Clinical Support

Full Name*
First Name Last Name
Email Address*
Please use your main work email. This will be used for notifications of orders or content access.
Enter Email Confirm Email
Account Login Password*
Enter Password Confirm Password

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Company Name*
Clinic Phone Number*
Mobile Number*
Address*
Street Address Address Line 2 City State Postcode Country
Confirm Agreement to Terms & Conditions of Trade*
I confirm and agree.
I certify that the above information is true and correct. I have read and understand the TERMS AND CONDITIONS OF TRADE (Viewable Here) of A Natural Difference Australia Pty Ltd T/A ClinicalPRO which form part of, and are intended to be read in conjunction with this Customer Information Form and agree to be bound by these conditions. I authorise the use of my personal information as detailed in the Privacy Act clause therein. I agree that if I am a director/shareholder (owning at least 15% of the shares) of the Customer I shall be personally liable for the performance of the Customer’s obligations under this contract.
Security
Name
This field is for validation purposes and should be left unchanged.

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