New Customer Registration Form

New Customer Registration Form

Cottonwood Labs - New Account / New Practice
Customer Details:
Name of Practice*
Name of Doctor*

PrefixFirst NameLast NameSuffix
Name of Main Contact for Practice*

PrefixFirst NameLast NameSuffix
E-mail for Main Contact*
example@example.com
Phone Number for Main Contact*
Approximate Number of Employees *
Estimated average number of Appliances to be requested, monthly*
Is your practice affiliated with a DSO or any other additional party billing type organizations?*

YesNo
DSO or other "Billing" Account Affiliates (if applicable)
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Address - If Different than Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, (please print name) referred to as (Guarantor), agree to all terms and conditions; and am the responsible person for any/all payments, including unpaid balances for the account of (please print name of practice / business) that is owed to Utah Medical Products and Services (DBA Cottonwood Labs).

As Guarantor, I understand that all balances past 60 days are subject to interest changes and non-payment fees; and accept full responsibility as Guarantor to pay all undisputed invoices past 90 days. Any account past 90 days is considered delinquent and is subject to all fees incurred to collect on all open invoices.

Please feel free to request a copy of our terms and conditions.
Signature of Guarantor

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How did you hear about us?*
Please Specify*
We use a "Customer Portal" so submitting cases and scans; and seeing real time updates is as easy as possible for the practices we work with. You can also see and pay invoices within the portal.

We understand that for quality and regulatory purposes, an Rx must be submitted with each case, regardless of how case is submitted.
Who will need portal access ?*
Name
Email
Name
Email
Name
Email
Anything else you would like us to know?
Should be Empty: