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:*
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
*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 my Credit Card Upon Order Fulfillment- (To securely store your card on file, select "Click Here to Pay" on your invoice, enter your card details, and check "Save payment for future purchases")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
*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 orders@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