Bank Details

Please complete the below KYC form so that Quitmate can reimburse your pharmacy for any online orders.

Pharmacy Trading Name(Required)

Registered Business Name

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.

Terms & Conditions

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