DCO Registration

Please complete the below KYC form to register for Quitmate. Our team will be in touch with next steps.

Pharmacy Trading Name(Required)

Registered Business Name

Email Address(Required)

This will be used to create the Quitmate account

Bank Details(Required)

BSB Account Number

Copy of Bank Details(Required)

Please upload a bank statement showing the name of your Pharmacy and BSB. No other details required.

Max. file size: 256 MB.

Name of Authorised Person Completing the Form(Required)

Terms & Conditions

I agree to the Quitmate Terms and Conditions and Privacy Policy.