AUS Practitioner Account Application

Access to SIV Biome Balancing Serum only
- Tick if you are a Skin Aesthetician/Beauty Therapist and want access to SIV’s Biome Balancing Serum product only
Business Validation and Practitioner Details
- Products and testing services must be prescribed to patients by a fully qualified and practising health practitioner in the context of a private consultation.
- To be recognised as a Qualified Healthcare Practitioner, completion of ‘tertiary equivalent’ education in an ‘ingestible’ clinical modality, that includes training in clinical nutrition, from a recognised educational institution must be evidenced. (Qualifications must be approved by FxMed to qualify as a health practitioner).*
- I hereby certify that I am a Health Professional as defined by the Therapeutic Goods Act.
CONFIRMATION OF CRITERIA BEING MET:*
- Yes, I meet all the criteria outlined above
Practitioner Details:
Practitioner Title
Full Name*
Qualifications*
Please upload a copy of your qualification/s*
File upload have a maximum size of 10MB. If you’re having trouble uploading, try compressing the file size or use a phone camera to take a photo to upload.
Drop files here or

Accepted file types: jpg, gif, pdf, png, tiff, jpeg.
Relevant Professional Membership/s

Save and Continue Later

Business Details
Full legal name of business*
Postal Address*
Street Address Suburb/Town State Postal Code
Delivery Address*
Street Address Suburb/Town State Postal Code
Specific Delivery Instructions
Clinic Contact Number*
Mobile/Other Contact Number
Email Address*
Administration Contact*
Accounts Department Email: (if different)
Business Type*
For Companies and Partnerships please list full name and address of Proprietors/Directors/Partners:

Save and Continue Later

Payment Terms
Payment Terms*
Payment Method*
Please note FxMed reserves the right to withdraw credit facilities at its sole discretion.
Please supply two trade (Nutritional) credit references below. We hereby give authorisation to FxMed to investigate our Credit References.

Save and Continue Later

If you wish to purchase RN Labs products – please see details of RN Labs Supply Policy.
Please note RN Labs Pty Ltd needs explicit compliance with the following terms and conditions when ordering or authorising their product range.
- Private Consultation: RN Labs products must be prescribed during a private consultation and cannot be issued following brief in-store or online consultations.
- Educational Qualification: Practitioners must have completed tertiary-level education in a clinical modality that includes training in clinical nutrition from an accredited institution.
- Current Association Membership: Practitioners must have a current membership with an Australian association that governs registered health or natural health professionals
- Storage and Display Restrictions:  RN Labs practitioner-only products must not be stored or displayed in retail settings, including online sales platforms.
- Client Log Book: All Retailers will need to maintain a log book for any clients that are prescribed RN Labs products.

Save and Continue Later

Signature
AUTHORISATION TO COMPLETE REGISTRATION*
- I hereby certify that I am the Company Owner or Director for completing this registration.
Confirmation*
- I confirm that the information I have supplied is correct. I have also read and agree to the Terms and Conditions of my account stipulated by FxMed on the top right of this page.
Your Full Name*
Date*

Save and Continue Later

Confirmation Summary
Please check your responses below prior to submitting your online application form. {all_fields}
When your account has been opened, you will receive an email from us containing your account number and online login details so you can access FxLearn and the Practitioner Hub (for ordering, patient ordering and to access resources). {all_fields}

Save and Continue Later

[email protected]