1. You may download and fill this Purchase Account Setup From then fax to: 1-866-787-4776. One of our representatives will contact you to complete the registration process.
   
2. Call us at 920-626-6222 to create an account. We’ll be happy to assist you with registration process.
3. You may utilize this online form to submit your facility information. You will be notified via email after your account has been setup and ready to order.
   

Important: Once your facility is registered you will be assigned an account number. Please keep this account number in a safe place and you must use this account number to place orders online or via fax.

* denotes required field

Facility Name:*

Type of Facility:*

Select ... Dental Office / Clinic Distributors / Wholesale Supply Hospital Institute / College / University Laboratory Medical Office / Clinic

Is this a Tax Exempt Facility?*

Yes

No

Your Name:*

Email:*

Phone:*

Fax: *

Business Address:*

City*

State:*

Zip Code:*

Additional Notes / Comments:

1000 characters remaining

I certify that; I am authorized representative / purchasing manager for this facility and the information submitted on this form is true and correct.*

Enter the code shown:

Privacy Note:

We value your privacy. Information collected on our website is strictly for our office use only. We may use this information to communicate special offers & promotions and send order information to our customers. We do not sell or share customer information with third party.