New Customer Service Setup

New Customer Form
1. Practice Information
Practice Name
Name of dental practice
DBA / Alternate Practice Name (optional)
Doctor / Owner Name

PrefixFirst NameLast Name
Specialty
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Office Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email for Estimates
example@example.com
2. Service Contact
Service Contact Name
Position / Title
Direct Phone
Please enter a valid phone number.Format: (000) 000-0000.
Service Contact Email
example@example.com
Preferred Communication Method
3. Billing Contact
Billing Contact Name
Billing Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Billing Email
example@example.com
4. Payment Authorization
Payment Authorization & Card on File Policy

QDS requires a valid credit card authorization form to be kept on file prior to scheduling service, repairs, installations, or equipment deliveries. Service may be delayed or declined until required payment authorization documentation has been received and approved.

Download Credit Card Authorization Form

Please click this link to download, complete, and sign the Credit Card Authorization Form.

Completed forms may be:

uploaded below, OR
emailed to: info@qds.dental
File / images upload

Cancelof
All checkboxes required before submission
5. Authorized Signature
Authorized Representative Name
Title
Signature
Date

MonthDayYear
Date
Submit Request

Once submit is clicked, your submission will be sent to us and you will be redirected back to qds.dental!
Should be Empty:

New Customer Form

1. Practice Information

2. Service Contact

3. Billing Contact

4. Payment Authorization

All checkboxes required before submission

5. Authorized Signature

Submit Request