create-account | Valiant Pharmacy

Account Registration Disclaimer:

Only qualified healthcare professionals who are duly registered with the relevant regulatory authority in Namibia are permitted to create and maintain an account. By registering, you confirm that you hold valid professional registration within Namibia and that all information provided is accurate and verifiable. Any accounts found to be in violation of this requirement may be suspended or terminated.

Create an account

1. Applicant Category

Select the type of healthcare professional applying for the account.

Applicant category *

2. Business / Practice Information

Provide the official business, practice, contact, and delivery details for this account application.

Company/Practice name *

Telephone number *

Postal Address

Delivery Address *

Email Address for statements *

3. Responsible Healthcare Professional Information

Provide the details of the doctor, responsible pharmacist, or authorised healthcare professional linked to this account.

Full name and surname *

Cell phone *

Email Address *

4. Owner Information

Provide the details of the owner or person legally responsible for the account.

Full name and surname *

Cell phone *

Email Address *

5. Bank Account Details

Provide the banking details linked to the account application in case of refunds.

Account Name *

Bank Name *

Type of Account *

Account Number *

Branch Name *

Branch Code *

6. Trade / Credit References

Required for credit account applications. Provide two supplier or business references who can confirm your payment history.

Company name

Telephone number

Contact Person

Company name

Telephone number

Contact Person

7. Supporting Documents

Upload the required documents needed to verify and process the account application.

Company Registration Documents *

Bank Confirmation Letter *

Not older than 3 months

Certified Copy of ID of Owner *

Certified Copy of ID of Responsible Healthcare Professional *

HPCNA Registration of Company *

Please note: This will be requested annually

HPCNA Registration of Responsible Healthcare Professional *

Please note: This will be requested annually

MoHSS Certificate *

Please note: This will be requested annually

Submit

After submitting this application, Valiant Pharmacy will send you an electronic signature request via our Sign application. Please complete the signature request promptly, as your account application cannot be finalised until all required documentation and signatures have been received.