First Name*

Last Name*



Date of birth*

National Insurance Number*



I am registering as* IndividualCompany

If you are registering as a company please complete the following information:

Company Name

Company Number

Country of Registration

Company Address

Company Postcode

You are required by law to provide confirmation of your identification to comply with Anti-Money Laundering Laws.

Please submit one document from list A and one document from list B.
Identification document - list A:

Identification document - list B:

If you have registered as a representative of a UK company please also upload one document from list C:

Are there any other individuals or entities with 25% or more shares or voting rights in the company?
NoYes - we will contact you to gain further verification.

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From time to time Designated Medical would like get in touch about our services. Please tick to say how we can contact you: EmailTelephoneText