NZ Practitioner Account Application

Step 1 of 6 – Business Validation and Practitioner Details

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).*
CONFIRMATION OF CRITERIA BEING MET:*
- Yes, I meet all the criteria outlined above
Practitioner Details
Practitioner Title
Full Name*
Qualifications*
Verification*
Upload a copy/photo of your qualifications or let us know if your name is listed on one of the registers below.
- Upload a copy/photo of qualification
- Medical Doctor (listed on mcnz.org.nz directory)
- Chiropractor (listed on chiropracticboard.org.nz directory)
- Dieticians (listed on dietitiansboard.org.nz directory)
- Osteopaths (listed on osteopathiccouncil.org.nz directory)
- Pharmacists (listed on pharmacycouncil.org.nz directory)
Please upload a photo or 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

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Business Details
Full legal name of business*
Are you GST registered?*
- Yes
- No
GST number:*
Postal Address*
Street Address Suburb Town/City Region Postal Code
Delivery Address*
Street Address Suburb Town Region 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:

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Payment Terms
Payment Terms*
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

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AUTHORISATION TO COMPLETE REGISTRATION*
- I hereby certify that I am the Company Owner or Director for completing this registration.
Your Full Name*
Date*
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.

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Confirmation Summary
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).
Please check your responses below prior to submitting your online application form. {all_fields}

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[email protected]

NZ 0800 439 633

AU 1800 770 904

PATIENTS

PATIENTS

Apply for a New Zealand Practitioner Account

Step 1 of 6 – Business Validation and Practitioner Details

Business Validation and Practitioner Details:

Practitioner Details

Business Details

Payment Terms

Establishing your needs

Request for Printed Product Catalogues

Confirmation Summary

Office Hours

Join the conversation

Practitioner Referral Only

Register with FxMed