{"id":293,"date":"2025-11-10T01:24:18","date_gmt":"2025-11-10T01:24:18","guid":{"rendered":"https:\/\/www.aftpharm.com\/za-en\/?page_id=293"},"modified":"2025-11-10T01:29:45","modified_gmt":"2025-11-10T01:29:45","slug":"professional-form","status":"publish","type":"page","link":"https:\/\/www.aftpharm.com\/za-en\/professional-form\/","title":{"rendered":"Healthcare Professional Registration"},"content":{"rendered":"\n<h1 class=\"wp-block-heading\" style=\"font-size:30px\">Healthcare Professional Registration<\/h1>\n\n\n<style id=\"wpforms-css-vars-297-block-10b69a61-9835-473a-adf4-e0bd1769fde0\">\n\t\t\t\t#wpforms-297.wpforms-block-10b69a61-9835-473a-adf4-e0bd1769fde0 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-10b69a61-9835-473a-adf4-e0bd1769fde0 wpforms-render-modern\" id=\"wpforms-297\"><form id=\"wpforms-form-297\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"297\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/za-en\/wp-json\/wp\/v2\/pages\/293\" data-token=\"e33315e6346e921f51d01773360b2f91\" data-token-time=\"1776555539\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator circles\" data-indicator=\"circles\" data-indicator-color=\"#066aab\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"3\" tabindex=\"-1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\" data-page=\"1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#066aab\" data-page=\"1\">1<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-2\" data-page=\"2\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"2\">2<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-3\" data-page=\"3\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"3\">3<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-297-field_3-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"3\"><\/div><div id=\"wpforms-297-field_23-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"23\"><div id=\"wpforms-297-field_23\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-297-field_23-error\"><h4>Important Disclaimer regarding the Prescription Range<\/h4>\n<p>The information contained in the Prescription Range section of the Website is intended for registered healthcare professionals only and is provided for informational purposes regarding AFT&#8217;s products. Such information does not constitute medical advice and is not intended for self-diagnosis, self-medication or the inappropriate use of any of AFT&#8217;s products. If you are not a registered healthcare professional, please click &#8220;Exit&#8221;.<\/p>\n<p>By clicking &#8220;Proceed&#8221;, you confirm that you are a registered healthcare professional and you agree to be bound by this Disclaimer. To learn more, please visit our <a href=\"\/za-en\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> and <a href=\"\/za-en\/terms-of-use\/\" target=\"_blank\">Terms of Use<\/a>.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-297-field_24-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"24\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"297\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Proceed<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-297-field_9-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"9\"><div id=\"wpforms-297-field_9\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-297-field_9-error\"><p>Fill out the form below, and we will be in touch shortly.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-297-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-297-field_11\">Profession <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-297-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"Doctor\"  selected='selected' class=\"choice-1 depth-1\"  >Doctor<\/option><option value=\"Pharmacist\"  class=\"choice-2 depth-1\"  >Pharmacist<\/option><option value=\"Nurse\"  class=\"choice-3 depth-1\"  >Nurse<\/option><option value=\"Others\"  class=\"choice-4 depth-1\"  >Others<\/option><\/select><\/div>\t\t<div id=\"wpforms-297-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-297-field_1\" >Link conditions HCP<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-297-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-297-field_12-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-297-field_12\" aria-hidden=\"false\">HPCSA Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-297-field_12\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"aa[a] [9][9][9][9][9][9][9]\" name=\"wpforms[fields][12]\" placeholder=\"HPCSA Number*\" aria-errormessage=\"wpforms-297-field_12-error\" required><\/div><div id=\"wpforms-297-field_19-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-297-field_19\" aria-hidden=\"false\">SANC Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-297-field_19\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"[9][9][9][9][9][9][9][a][a][a]\" name=\"wpforms[fields][19]\" placeholder=\"SANC Number*\" aria-errormessage=\"wpforms-297-field_19-error\" required><\/div><div id=\"wpforms-297-field_20-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"20\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-297-field_20\" aria-hidden=\"false\">SAPC Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-297-field_20\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"A[9][9][9][9][9][9][9][9]\" name=\"wpforms[fields][20]\" placeholder=\"SAPC Number*\" aria-errormessage=\"wpforms-297-field_20-error\" required><\/div><div id=\"wpforms-297-field_22-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"22\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-297-field_22\" aria-hidden=\"false\">HPCSA Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-297-field_22\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"[a][a][a][9][9][9][9][9][9][9]\" name=\"wpforms[fields][22]\" placeholder=\"HPCSA Number*\" aria-errormessage=\"wpforms-297-field_22-error\" required><\/div><div id=\"wpforms-297-field_14-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"14\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"297\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"297\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 last \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-297-field_18-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"18\"><div id=\"wpforms-297-field_18\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-297-field_18-error\"><p style=\"font-size:16px;margin-bottom:0\"><strong>Please read and accept <a href=\"https:\/\/www.aftpharm.com\/za-en\/terms-of-use\/\" target=\"_blank\" rel=\"noopener\">terms and conditions<\/a> to continue.\u00a0<\/strong><span style=\"color:#ff0000\">*<\/span><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-297-field_16-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Please read and accept terms and conditions to continue. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-297-field_16\" 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