New Client Account Application Form This form is for new clients applying for an account. Please complete all of the fields below. For existing clients updating information, please refer to the Client Update Form
Business Information
Proprietors or Directors
Trade References
Department/Divisional Specific Information
Invoicing for Medicals, Travel & Company Funded Services
Invoicing for Worker’s Compensation & Injury Management
Medical Results Report
(Please Note: An additional administration fee is charged when own paperwork is requested)
Preferred Prime Clinics
You must agree to the Terms and Conditions before completing this form.