Flow Herbal Dispensary Application Form

Thank you for registering to prescribe through our botanical dispensary. We require that practitioners are qualified to prescribe botanical medicine and possess active licensure and insurance for their practice.

Please complete the following form and attach your valid practice permit or proof of active licensure. Upon receipt, we will review your application and verify its completeness before confirming your registration.

Name

First Name

Last Name

Professional Designation

Professional Number

Address

City and Province

Postal Code

Phone

(###)

###

####

Website

http://

I agree that as the prescribing practitioner, I carry full liability for any and all prescriptions submitted and am responsible for any complications or adverse reaction experienced by my patient/client.

Yes

I am currently registered to practice and have valid insurance

Yes

Date

YYYY

Flow Herbal Dispensary Application Form

Clinic info

Solutions