Services Payment Form

Services Payment Form

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Proprietor Details
Proprietor Name

First NameLast Name
Proprietor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Proprietor Email
example@example.com
Secondary Contact (if Applicable)
Secondary Contact Name

First NameLast Name
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Email
example@example.com
Business Information
Pharmacy Name
ABN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Service Consent

Before proceeding with your booking, please review the following consent information. By continuing, you acknowledge and agree to the conditions below.
Your Consent

By submitting this form, I confirm that:
- I am aware of the relevant legislation and professional obligations that apply to pharmacists and pharmacy proprietors.
- I acknowledge the Pharmacy Board of Australia’s Guidelines for pharmacists on the safe provision of pharmacy services including medicines and advice, under Leadership/management in practice where:
  - “proprietors remain accountable for ensuring that the pharmacy business is conducted safely, ethically, professionally and in accordance with legislation and related information such as guidelines”.
- I request to access this service and understand that participation is completely voluntary.
- I have been informed of, and agree to pay, the applicable service fees and charges.
- I agree to be an active participant in meeting the requirements of legislation, professional practice standards, and codes of conduct relevant to pharmacists and pharmacy businesses.
- I understand that pharmacy coach services are advisory and educational in nature, and that my pharmacy, pharmacists, and staff remain responsible for meeting all Commonwealth, State, and Territory legal and regulatory obligations.
- The audit report provided is a guide and should not be taken as legal advice. It is a special purpose assessment compiled exclusively for the benefit of the pharmacy proprietors who are responsible for the reliability, accuracy and completeness of processes, procedures and policies for compliance for requirements in the Act and Regulation requirements in their jurisdiction.
- I acknowledge that I am responsible for any additional service costs when informed in writing.
- I understand that pharmacy coach protects privacy and confidentiality in accordance with the Australian Privacy Principles and the Privacy Act 1988 (Cth).
- I acknowledge that pharmacy coach pharmacist auditors act in my professional interests and focus on adherence to industry standards.
- I consent to AI-assisted transcription of audit notes solely to streamline the audit process, documentation, and follow-up reporting.
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Services Payment Form

Proprietor Details

Secondary Contact (if Applicable)

Business Information

Product Information

Service Consent