New Account Setup Form

New Account Setup Form
Sales Representative
Practice Information:
If your practice is a part of a Private Equity or Doctor Alliance Group, please include the name of the Parent Company below:
Practice Name:
Provider Name:

First NameLast Name
Provider Type:
Provider Email:
Provider Email:
Ship To Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number:
Format: (000) 000-0000.
*Recipient Name
*Order shipments will be addressed to the recipient above
Recipient Title
*Recipient Email:
*Order confirmations & tracking details will be addressed to the recipient above
*Recipient Email:
*Order confirmations & tracking details will be addressed to the recipient above
*Billing Information:

*Billing information not required if you select "Yes" below.
Billing information is the same as shipping?
Bill to Account Name:
Bill To Account Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Method?
Credit Card Billing Preference
*Accounts Payable Email:
*This email will receive order invoices from DefEYE, Inc. as applicable
*Accounts Payable Email:
*This email will receive order invoices from DefEYE, Inc. as applicable
Additional Comments:
Applicant Signature:
*To place an order, please reach out directly to your DefEYE Sales Representative
Contact us at: +1 (786) 723-7178 or orders@defeye.com
www.defeye.com
DefEYE, Inc.
1990 Main St. Suite 750, Sarasota, FL 34236
Should be Empty:

Practice Information: