Become a Practitioner

Become a practitioner Form

All fields marked with * are mandatory.

IMPORTANT – Should the form not be signed in full, the application will be void

Applicant Information

Practice:

Please upload your headshot or logo for your listing on our website

Max Size: 32MB | Format: jpg, png, pdf

Dispensing License?

YesNo

Personal

Date of Birth:*

Wedding Anniversary:

Where did you hear about us?

InternetSocial MediaAdvertisingColleague / Friend / Word of MouthOther

Were you referred by a fellow doctor?

YesNo

If yes, who was your referring doctor?

What information do you want customers to see on the Slender Wonder website?

Education & Occupation

Qualifications

Acknowledgements:

By clicking here, you acknowledge and agree to read and practice the Slender Wonder protocol to its fullest extent. You understand that adherence to the protocol is essential for the program's successful outcome.

By clicking here, you acknowledge and agree that you are aware of the protocol stipulations regarding hCG. You understand the importance of complying with the hCG guidelines as part of the Slender Wonder program and its impact on achieving successful weight loss and overall health improvement (https://slenderwonderdoctors.co.za/hcg-acknowledgement/).

By clicking here, you acknowledge and agree to the confidentiality terms and conditions. You understand and agree to treat any confidential information provided to you with utmost privacy and not to disclose or use it in any way other than for the intended purpose. (https://slenderwonderdoctors.co.za/confidentiality-acknowledgement/).

Disclaimer

I certify that my answers are true and complete to the best of my knowledge. I understand that it is at the sole discretion of Slender Wonder TM to accept my application, or revoke my status as a Slender Wonder TM Practitioner.

I hereby acknowledge that I understand and agree to the above mentioned statements.

Protection of Personal Information Act (POPI Act) - POPIA

I hereby consent to the personal information provided by me to be used for delivery of services offered by Slender Wonder.
It is my legal obligation to provide correct information in the contracting with Slender Wonder and where such information has been changed, I am obliged to inform
Slender Wonder accordingly.
I am aware that I can unsubscribe to any newsletters, campaigns, communications from Slender Wonder by notifying them accordingly.
It is my right to request Slender Wonder to delete and cease to use any of my personal information subject to any legal obligation on Slender Wonder’s side to keep same.
There is a legal obligation for Slender Wonder to retain your information for 5-years from date of contracting, whereafter it will be destroyed in a POPIA compliant
manner.
Should I believe that there has been a misuse of my personal information, I am aware that I can lodge a complaint with Slender Wonder and / or the Information Regulator at inforeg@justice.gov.za

I hereby acknowledge that I understand and agree to the above mentioned statements.

Signature

Printed Name*

Date of issue*

NOTE - Please use your mouse or trackpad to create your signature

Practitioner signature*

(IMPORTANT - Should the form not be signed in full, OR, a full signature uploaded the order will be void)

NOTE - Please upload your signature

Formats (JPEG, PNG, PDF)

I confirm I signed in full

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