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New Account Request

Want to set up a Urethrotech account?

Please provide us with your billing and shipping information to set up a new Customer Account. A sales representative will contact you by email within 24 hours to follow-up.
MM slash DD slash YYYY
(open a Urethrotech Account for this facility)
(who is completing this form?)
Contact Name(Required)
Email(Required)

FACILITY INFORMATION

1. BILLING INFORMATION

(who will receive the invoice?)
Address

Accounts Payable

(who will deal with the invoice?)
Email (Accounts payable)
(Accounts payable)
Tax Exempt

CC. Contacts

(stakeholders involved with new product onboarding you like us to know about)
Email (cc. contact)
Email (cc. contact)
Email (cc. contact)
Email (cc. contact)
Email (cc. contact)

2. SHIPPING INFORMATION

(where should we ship the goods to?)
Name (Attention To)(Required)
(who should receive the goods?)
Email (Attention To)(Required)
Ship To Address(Required)
warehouse / goods receiving bay
The 13-digit GLN number identifies a physical locations such as a warehouse gate and delivery points.

3. PRICING AND CONTRACTS

Please complete this section in order to receive access to the correct pricing.
If 'Yes', please list which Coalition or GPO
Name (Supply Chain contact)
Email (Supply Chain contact)
Consent
This field is for validation purposes and should be left unchanged.
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