Auto Statement Application/Termination

Download the Application or Termination form
Complete the fields
Upload the completed form
Forward the form by selecting the pharmacy management software vendor email address

For further assistance contact our Customer Care enquiry line on +27 (0) 860-932-273

Pharmacy Provider: Auto Statement Application/Termination

"*" indicates required fields

Application Type*

Application

Termination

BHF nr*

Pharmacy or Pharmacy Group Name*

Name & Surname*

Phone Number*

Email Address*

Application Form*

Upload completed application form

Max. file size: 128 MB.

Select Pharmacy Management Software Vendor*

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.