Contact Details
Title (Mr, Mrs, Dr, Ms):

Initials:

Surname:

Qualifications:

Person responsible for paying ACC:

Address line 1:

Address line 2:

County:

Postcode:

Country:

Telephone number:

Fax number:

Email:

Website:

Contact name:

Do you currently have an account with Ortho-Care? Select Yes No

If yes, please give account number:

If you already have an account, please Ignore the below set-up details and press the send button.

 

Type of Account
Type of business: Select Orthodontist/Orthodontic Practice General Dental Practitioner Technician/Laboratory Other

Other description:

 

Orthodontist
How many days at this practice:

Any other orthodontists working at your practice: Select Yes No

If yes, please supply the name/s of the orthodontist/s:

Where are you currently buying the bulk of your orthodontic supplies from?:

 

General Practitioner / Laboratory

Will you be buying from us again?: Select Yes No

Credit reference 1:

Credit reference 2:

 

Additional Information

Would you like a visit from my local representative? (by appointment only): Select Yes No

Would you like us to send you our catalogue and pricelist?: Select Yes No

Would you like us to add you to our mailing list?: Select Yes No

Please tell us the products you are interested in?: