Register to Start Purchasing

Complete the form below to create your account. Fields marked with a red asterisk are required. Your application will be reviewed before account activation some product categories require regulatory verification.

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

1. Contact Details

Primary contact for this account

Contact Salutation*

Account / Organisation Name*

Full Name*

First Last

Contact Phone*

Contact Email*

2. Business Details

Organisation registration and type

ABN (Australian Business Number)*

11-digit ABN, used to verify your business registration

Type of Business*

Public Hospital

Private Hospital

Private Clinic / Day Surgery

Pharmacy

Distributor / Wholesaler

Aesthetics Clinic / Salon

Other

Please describe your business type

3. Billing Address

Primary billing address for invoicing

Address*

Street Address Address Line 2 City / Suburb State Postcode

4. Shipping Address

Where orders will be delivered, leave blank if same as billing

Same as business address

Shipping address is the same as billing address

Address

Street Address Address Line 2 City / Suburb State Postcode

Delivery Instructions

Optional, include anything our team needs to know for successful delivery

5. Product Access & Qualification

Select all product categories you intend to order, restricted categories require regulatory verification

Which product types will you order?*

(Select all that apply)

Pharmacy Medicines (Schedule 2 / Schedule 3 / Schedule 4 / Schedule 8 Restricted, requires AHPRA number, prescriber number, or licence; includes OTC pharmacy, prescription, and controlled medicines

Medical Devices (general, surgical instruments, implants, diagnostics Healthcare facility or practitioner verification required

Ionising Radiation Devices (X-ray, fluoroscopy, CT, brachytherapy, nuclear medicine) Restricted, requires state/territory radiation use licence and facility radiation management licence

Energy-Based Devices (surgical lasers, IPL, radiofrequency, HIFU, cryotherapy)Requires qualified clinical operator

Cosmetic Injectibles & Associated DevicesRestricted, requires AHPRA registration of supervising medical practitioner

Cosmetic / Aesthetics Products (non-injectable topical products)

Please provide qualification / training details to support purchase of products.*

📞 After submitting this form, please contact Customer Success to place your order on 1300 00 3636

⚠ Qualification: Pharmacy Medicines (Schedule 2 / 3 / 4 / 8)

Which best describes your organisation for the purpose of ordering scheduled pharmacy medicines?*

Licensed pharmacy (community or hospital)PBS-approved pharmacy or state/territory premises registration

Registered healthcare practitioner, purchasing for use in clinical practice Doctor, pharmacist, nurse, or other AHPRA-registered practitioner

Authorised distributorRequires state-issued licence, see Business Details section

None of the above

Pharmacy Credentials

PBS Approval Number

Responsible Pharmacist, AHPRA Number*

AHPRA-registered pharmacist in charge of the premises

Premises Registration / Business Licence Number

Issuing Authority

Healthcare Practitioner Credentials

Practitioner Full Name*

AHPRA Registration Number*

Medical (MED), Nursing/Midwifery (NMW), Pharmacy (PHR), or other board prefix

Profession / Registration Type*

Practice / Clinic Name

The organisation where these products will be used

Medicare Prescriber Number

Required for Schedule 4 / 8 prescription access

Distributor Licence Details

Distribution Licence Number*

Issuing State Authority*

⚠ Not eligible: Scheduled pharmacy medicines cannot be supplied to this organisation type. Please contact Endotherapeutics for further assistance on 1300 00 ENDO (3636).

⚙ Qualification: Medical Devices

Practitioner / Facility Qualification

Responsible Practitioner / Facility Contact*

AHPRA Registration Number*

If applicable Medical (MED), Nursing/Midwifery (NMW), or other board prefix

Practitioner Role / Designation

Facility / Department

☀ Qualification: Ionising Radiation Devices

Radiation Licence Details

Does your facility hold a current radiation use or radiation management licence?*

Yes licence held

No / In progress

Radiation Licence / Permit Number*

Issuing State / Territory Radiation Authority*

Radiation Safety Officer (RSO) Name

Recommended, required for some device types and jurisdictions

⚠ Licence required: Access to ionising radiation devices will be pended until a valid licence is provided. Please contact Endotherapeutics for further assistance on 1300 00 ENDO (3636).

☂ Qualification: Energy-Based Devices (Lasers / IPL / RF / HIFU)

Clinical Operator Details

Responsible Clinician / Operator Full Name*

AHPRA Registration Number (if applicable)

Required if operator is an AHPRA-registered practitioner

Operator Role / Qualification*

Clinical Setting

Laser Safety Certificate or Relevant Training*

Required for all operators

✧ Qualification: Cosmetic Injectables & Associated Devices

Supervising Practitioner Details

Does your facility have an AHPRA-registered medical practitioner responsible for supervising the use of cosmetic injectables and/or associated devices?*

Yes

Supervising Practitioner Full Name*

AHPRA Registration Number*

Medical (MED), Nursing/Midwifery (NMW), or Pharmacy (PHR)

Practitioner's Role / Title

⚠ Medical supervision required: Access to cosmetic injectables may be declined without valid supervising practitioner details. Please contact Endotherapeutics for further assistance on 1300 00 ENDO (3636).

Primary Treating / Ordering Practitioner (if applicable)

For accounts where a specific practitioner authorises orders

AHPRA Number (ordering practitioner)

Consent*

I declare that the information provided is accurate and complete. I acknowledge that my organisation's credentials including AHPRA registrations and radiation licences may be verified through publicly available registers and relevant authorities before activating this account. I understand that providing false information may result in account termination.*

Your information is handled in accordance with our Privacy Policy and the Privacy Act 1988 (Cth).
Personal information collected here is used solely for account setup, order processing, and regulatory compliance.

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* Delivery within Australia only. Delivery options vary by location.

Register to Start Purchasing

1. Contact Details

2. Business Details

3. Billing Address

4. Shipping Address

5. Product Access & Qualification

⚠ Qualification: Pharmacy Medicines (Schedule 2 / 3 / 4 / 8)

Pharmacy Credentials

Healthcare Practitioner Credentials

Distributor Licence Details

⚙ Qualification: Medical Devices

☀ Qualification: Ionising Radiation Devices

☂ Qualification: Energy-Based Devices (Lasers / IPL / RF / HIFU)

✧ Qualification: Cosmetic Injectables & Associated Devices

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