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Personal Information

Where are you located?

Please select which companies you would like to open an account with:*

Andent

SCD

Gold & Ceramics

Please select which companies you would like to open an account with:*

SCD

Precision

Your Dental Registration*

Lookup APHRA

Dental Council of NZ registration number*

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Lookup DCNZ

Full Name*

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I'm not a dentist

If not a dentist, please select the option below:*

Preferred Name

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Dentist Email*

Mobile*

Does your practice belong to a Corporate Group?*

Yes

Which Corporate group do you belong to?*

Other Corporate group

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Are you responsible for payment of invoices?*

Yes, I am

No, payment managed by Head Office I have authority to create an account under this corporate head office

Trading Name*

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ABN*

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Lookup Australian Business Number

NZBN*

Lookup New Zealand Business Number

Have you had an account with any of these labs before??

Have you had an account with any of these labs before?

If yes, what was your account number?

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Practice Details

Practice Name*

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Practice Address*

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Practice Address 2

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State*

Postcode*

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Suburb*

Town/Region*

Postcode*

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Is your Delivery Address different to your Practice Address?

Postal Address*

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Postal Address 2

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State*

Postcode*

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Suburb*

Town/Region*

Postcode*

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Practice Phone*

Practice Contact Name

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Position

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Digital Scanners

Trios

CS-Connect

Sirona-Connect

iTero

MeditLink

DEXIS

Other

Please Mention*

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Practice Email*

Account Email

Add Promo Code?

Promo Code*

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