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:*

MDDOOD
Provider Email:*
Ship To Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number:*
*Recipient Name*
*Order shipments 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?*

YesNo
Bill to Account Name:
Bill To Account Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Method?*

ACH/ePayable (Net 30)Check (Net 30)Credit Card (select billing preference below)
Credit Card Billing Preference

Charge Credit Card (Upon Order)- Your card on file will be charged at the time of order placement.Charge Credit Card (Net 30) - Your card on file will be charged automatically after 30 days.Do Not Charge My Credit Card (Net 30) - I will submit payment via Credit Card within 30 days, per invoice.
Accounts Payable Email:*
*This email will receive order invoices from DefEYE, Inc. as applicable
Additional Comments:
Applicant Signature:*

Clear
*To place an order, please reach out directly to your DefEYE Sales Representative
Contact us at: +1 (786) 723-7178 or info@defeye.com
www.defeye.com
DefEYE, Inc.
1990 Main St. Suite 750, Sarasota, FL 34236
Should be Empty:

New Account Setup Form

Practice Information:

*Billing Information:

*To place an order, please reach out directly to your DefEYE Sales Representative