Clinician Registration

PART 1

Title*

Name*

First Last

Email*

Phone*

Practice Name*

Discipline*

Your highest clinically-related qualification*

Institution*

Your Professional Association*

Your Association Membership Number*

Registered Company/Business Name:*

Website:*

City / Suburb*

State*

Country:*

Your specific clinical interest(s):*

Subscribe to Clinician Newsletter

Yes, I would like to receive Clinician Newsletters

PART 2

Access to Clinician-Only range: Integra Nutritionals Application (Essential for enrolling in the G.E.M.M. Foundation Course)

Yes, I would also like to submit my Application for access to the Integra Nutritionals Clinician-Only product range. Upon approval, all applicants (except Bridging Trainees) will be approved to study the G.E.M.M Protocol.

Integra Nutritionals Application

TERMS & CONDITIONS

1. PROFESSIONAL QUALIFICATIONS - An applicant requesting I.N. supply must (Select one):

1. Professional Qualifications Conditions*

a) Be a registered health professional with qualifications in nutrition, naturopathy, dietetics, biochemistry, or equivalent. (Nursing, Pharmacy, Homeopathy, Physiotherapy, Remedial Massage, Occupational Therapy and Health Coaching are not accepted.) For Pharmacy dispensing on behalf of an approved clinician, please refer to Section 4 (d).

b) OR as an Educator in the health professions, you may purchase the I.N. range on behalf of your institution’s training clinic. Please contact our office to obtain further information and conditions of purchase.

c) OR if you do not meet any of the nutrition and/or biochemistry requirements, you may be eligible to attend a bridging training session with a Clinician Educator. Upon successful completion, you will be approved to access the Integra Nutritionals range. Bridging trainees are not eligible to study the G.E.M.M Protocol, however are able to study nutrigenomics at our Institute for Nutrigenomic Medicine – www.nutrigenomicmedicine.com

2. CLINIC PREMISES

2. Clinic Premises Conditions*

a) The premises, whether for face-to-face or online consultations must be an enclosed, quiet and private area. Note that a retail outlet staffed by qualified clinicians but without an appropriate consulting room as described above is not eligible for I.N. supply.

3. THE CONSULTATION - Eligibility for I.N. supply requires that the clinician conducts a full consultation according to the following criteria:

3. Consultation Conditions*

a) The nature of the consultation, the content, the allocated timeframe and the generation of an appropriate management plan must meet professional standards as required by the relevant professional association. A questionnaire may form part of the consultation process but is not an adequate substitute.

b) The clinician must keep detailed dated case notes, including prescription and dosage notations for each patient; changes to prescription and dosage must be recorded at the relevant consultation. Such records must be stored securely and retained according to legal requirements of the relevant jurisdiction.

c) In recommending I.N. products, the clinician must issue a written/typed prescription which details the name of the formulation and the dosage. No I.N. technical data or promotional materials marked as ‘Clinician Only’, may be provided/supplied to the patient.

4. DISPENSING PRODUCTS IN THE I.N. RANGE

4. Dispensing Products Conditions*

a) Products in the I.N. range classified ‘for clinician dispensing’ may be dispensed in smaller and appropriately labelled containers as per professional guidelines.

b) Products in the I.N. range may not be openly displayed to the patient or others in the waiting area (prior to dispensing).

c) At no time should any I.N. product appear online in a non-password protected area, nor may it be sold in any non-clinical environment.

d) In a pharmacy, the Pharmacist agrees to treat I.N. products similarly to S4 medication and only dispense them upon receipt of a prescription from a qualified practitioner with Integra Nutritionals approval. Unqualified staff are not permitted to dispense I.N. products.

PERSONAL INFORMATION

First Name*

Last Name*

Email Address*

Phone Number*

CLINICIAN INFORMATION

Clinic Name*

Clinic Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website*

Your Professional Association*

Your Association Membership Number**

Membership Expiry Date*

Your qualifications*

Institution granting your qualification*

Year of Graduation from this Institution*

Please attach a copy of your highest nutrition/biochemistry relevant qualification*

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, rtf, , Max. file size: 20 MB.

Term and Conditions*

I have read and accept the terms and conditions listed above. I have read and accept all the terms and conditions presented on this page, with the exception of Items listed above as 1b and 5a. I understand that any breach of these terms & conditions on my part may result in cessation of supply on the Integra Nutritionals product range.

I Accept

Name

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

Your Access to Dedicated Clinician Resources

PART 1

PART 2

Integra Nutritionals Application

TERMS & CONDITIONS

PERSONAL INFORMATION

CLINICIAN INFORMATION

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