Novo Nordisk Saxenda | Saxenda® Network Pharmacy Registration eForm

Saxenda^® Network Pharmacy Registration eForm

Pharmacy Details

Pharmacy Name

Address Line 1

Address Line 2

Address Line 3

Suburb

State

Postcode

Banner Group

Insert 'Independent'if no banner

Phone Number

Fax Number

Nominated Pharmacy Owner First Name

Nominated Pharmacy Owner Last Name

Email

Pharmacist Details

Are you the Pharmacy Owner?

Other Email Address

Pharmacist In-charge First Name

What is your first name?

Pharmacist In-charge Last Name

Pharmacist In-charge Email Address

Add another Pharmacist?

Obligations for Reporting Safety Information

The applicant understands and accepts the obligations for reporting safety information

Obligations of the Saxenda® Network Pharmacy for reporting safety information

Additional Pharmacist Details

#1 Pharmacist First Name	Pharmacist Last Name
Pharmacist Email Address
#2 Pharmacist First Name	Pharmacist Last Name
Pharmacist Email Address
#3 Pharmacist First Name	Pharmacist Last Name
Pharmacist Email Address

Pharmacy Banking Details

Novo Nordisk Pty Ltd ABN 40 002 879 996 collects your banking information for the purpose of paying the professional fee for the pharmacy participating in the Saxenda^® Program. No funds will be debited from accounts without your consent.

Banking Details

Bank Name

Bank Account Name

Bank BSB

Bank Account Number

Wholesaler Details

Wholesaler Details

Primary Wholesaler Name

Pharmacy Wholesaler Account Name

Primary Wholesaler Number

Pharmacy consent *

Terms of use *

Privacy policy *

Saxenda® Network Pharmacy Registration eForm

Pharmacy Program

Novo Nordisk Pharmaceuticals Pty Ltd