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Request For Access
To access Naturopathic Medicines, please confirm your details so we can contact you regarding this request.
Expected completion time: 2-5 minutes
Current Product
Product Name
Product Handle
Product Vendor
Product ID
Patient Account Details
Please confirm the details below are correct. If see an error, please advise our support team using the option at the bottom of this form page.
Patient Account Details
SC Customer ID
Contact ID
Patient Details
Full Name
Date of Birth
Mobile Phone Number
Email Address
Are the details above current and accurate?
Please select...
Yes
No
Please provide the details below and our support team will update your account details:
Additional Products
You can add any additional products here to assist in processing your request. These details will be passed to our practitioner.
Your request will automatically include any variants such as flavours and sizes.
Current Product
This product is automatically included in your submission.
Additional Product/s (Optional)
Product Search
Additional Product ID
URL Domain
Product Slug
Brand
<Placeholder> Product Image
Patient Details
Do you have any pre-existing medical conditions?
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Yes
No
Have you taken the product/s before?
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No
Yes - currently
Yes - previously
How did you hear about the product/s?
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A practitioner referral
Social media (facebook, twitter, etc.)
Friend or family member referral
News program
An article/blog
Other - please describe
If you have a script from a practitioner, you can upload a copy below now or on your account page. This file will assist HealthMasters when assessing your request.
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File Type
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Prescription
Pathology
Practitioner Notes
Other
File Upload
Documents and images only