Registration Form

To access regulated products on our website, please fill in the form below to be approved by the Boston Medical Group Team. Once your application has been accepted will be able to activate your access.

General Information Please fill in all fields below
*Profession:

*Registration number:
e.g.: GMC, GDC, NMC etc.
*Title:

*Gender:

*Date of birth:

*First name:

*Surname:

*Email:

IDENTIFICATION DETAILS
*Please upload a valid photo ID document
For example, your passport or driving licence


*Please upload an up to date proof of address document
Must be no older than 6 months and stating your current name and address.
Must be a utility bill/bank statement (financial info masked)/HMRC Correspondence


Please note: In order to avoid delays in opening your account with us, please ensure your name is listed on the professional registration body (i.e GMC/NMC), is the same as your photo ID and proof of address
QUALIFICATION DETAILS
Please upload any relevant certificates which you may hold covering the treatments you are looking to carry out such as Dermal fillers, Chemical peels, etc.

INSURANCE DETAILS
Please upload any relevant insurance policies or certificates which you may be covered for relevant to the treatments you are looking to carry out.

WORK DETAILS
*Business/Clinic name:

Business VAT number (if applicable)

*Building number/name:

*Address line 1:

Address line 2:

*Town/City:

*Postcode:

*County:

*Country:

*Landline number:

*Mobile number:

Business website address:

Business social media accounts:



HOME/PERSONAL DETAILS
*Building number/name:

*Address line 1:

Address line 2:

*Town/City:

*Postcode:

*County:

*Country:

*Landline number:

*Mobile number:

We will verify your registration details and contact you if we require any further information as soon as possible, typically within 2 working days if all information you have provided is satisfactory. Thank you