Customer Application

Customer Application

for The Tooth Lab (Australia) Pty Ltd 2/237 Great North Rd, Five Dock NSW 2046 Phone: 1300 907 497 Email: info@thetoothlab.com.au
Practice details
ABN
ACN (if a company)
Dentist Name
Practice trading name
Registered entity name
Mailing Address

Practice Name

Address
CityStatePostcode
Practice phone

Area CodePhone Number
Email
example@example.com.au
Accounts contact
Name
Position or role
Direct phone

Area CodePhone Number
Accounts email
example@example.com.au
Billing address is the same as the practice address
Billing address

Street Address

Street Address Line 2
SuburbStatePostcode
Email invoices and statements to
Agreement
Account Terms
Credit checks and references

I authorise The Tooth Lab to obtain commercial and personal credit information about the applicant and its directors or proprietors from credit reporting bodies and other credit providers, to assess this application and manage the account, and to contact the trade references given above. I understand information about payment defaults may be disclosed to credit reporting bodies as permitted by law.
Your name
Your position
Should be Empty: