Practice Account Application Form

Your Personal Contact Details

Your Practice Manager's Details

Your Company Information
e.g. GP Practice, CCG, Charity, NHS Trust, Private Practice
e.g. Reading Clinical Commissioning Group (CCG) is made up of 51 GP member practices
This is normally the same as the name detailed on your Cheques e.g. Dr Smith's Practice or Dr Smith & Partners
If different to your legal trading name e.g. Reading Health Centre or The Reading Surgery
Your Company's Postal Address
Your Company Website Address e.g. www.numed.co.uk
Your Company Email Address e.g. info@numed.co.uk
National Administrative Code Service number. For more info see http://systems.hscic.gov.uk/data/ods
Your Electronic Patient Record Site number e.g. EMIS, TPP, InPS Site Number
If the information entered is the details of your branch site or sister site, for example where you would like the goods delievered. Please tick the box and enter the details of your Main Site.

Your Main Company Information

Other Information
Have you, your partner or your practice ever being the subject of a bankruptcy petition?
Is your practice subject to any new or ongoing financial litigation?

Declaration and Agreement

I/we declare that the above information is true, correct and complete and is given as a request for Numed Healthcare to extend credit payment terms to me/us. I/we authorise Numed Healthcare to make any necessary credit investigations by obtaining the relevant credit data. Numed Healthcare is the legal trading name of Numed Holdings Ltd, who will provide credit and who will be responsible for the costs in obtaining credit data and references. I/we have read and agree to the Terms and Conditions, for the of supply of all products and/or services, from Numed Holdings Ltd, which are available at www.numed.co.uk/terms-and-conditions

To authorise the form please type your full name in the box provided and then check the accompanying checkbox