Registration form - medidentsolution

Client Application Form

Thank you for your interest in partnering with MediDent Solution LLC. Please complete the following application to register your medical office as a client. Once submitted, our team will review your application and reach out with the next steps.

Business Name:

Business Type (e.g., Dental Office, Dental Practice, Clinic, etc.):

Tax ID / EIN (if applicable):

Street Address:

City:

State/Province:

Postal Code:

Country:

Street Address:

City:

State/Province:

Postal Code:

Country:

Email Address:

Website (if applicable):

Name:

Title/Position:

Phone Number:

Email Address:

Number of Employees (dentists, hygienists, etc.):

How long has your practice been in operation?

Estimated monthly supply spend:

Current dental supply company (if applicable):

Sales Representative Name:

Phone Number:

Email Address:

Preferred Payment Method:

Credit Card ACH (Bank Transfer) Other

Other:

Billing Address (if different from above):

By submitting this form, you agree to our standard terms and conditions, which include a commitment to providing timely payment for all orders and abiding by our customer policies. The company reserves the right to review and approve all accounts before processing orders.

Date

I have read and understand the Policies & Terms and agree to abide by them

Client Application Form

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Client Application Form

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