Create New Customer Account

Personal Information

Name

Prefix

First Name

Last Name

Address Information

Company

Phone Number

Street Address

Address

City

Region

Zip/Postal Code

Country

Sign-in Information

Password

Password Strength: No Password

Confirm Password

Additional Settings

I already have a Geistlich Account

Account Number

Business Information

Business Type

NZBN

Business and Credit Information

Nature of Business

How long have you been at your current address?

Credit limit required (estimated amount equivalent to 2 months purchases)

How many implants are placed at your practice per year?

1st Business/Trade Reference Please note the following companies do not provide references, please list other trade references: - Henry Schein - Dentsply Sirona - Ivoclar Vivadent - Healthcare Essentials - Oraltec - Aluro - Crown Medical

Company Name

Address

City

Region

Postcode

Phone

Fax

E-mail

2nd Business/Trade Reference

Company Name

Address

City

Region

Postcode

Phone

Fax

E-mail

Practitioner details

Practitioner 1

Dr Name

NZDC Dr 1

Specialty

Other Specialty

Practitioner 2

Dr Name

NZDC Dr 2

Specialty

Other Specialty

Practitioner 3

Dr Name

NZDC Dr 3

Specialty

Other Specialty

Practitioner 4

Dr Name

NZDC Dr 4

Specialty

Other Specialty

Practitioner 5

Dr Name

NZDC Dr 5

Specialty

Other Specialty

Sales Terms & General Information 1. All invoices are to be paid in 30 days from the date of the invoice. 2. Claims arising from invoices must be made within seven working days. 3. By submitting this application, you authorise Geistlich Pharma New Zealand Ltd. to make inquiries into the banking and business/trade references that you have supplied.

Confirmation

Yes

I confirm that the contact information set out in this form is correct and I consent to the possession and use of that information by Geistlich Pharma New Zealand Ltd.

Yes

I have read and agree to Geistlich Pharma New Zealand’s privacy policy

Sales Terms & General Information

Yes

I have read and agree to Geistlich Pharma New Zealand’s Sales Terms & General Information