New customer setup

About you

1. I am applying as: *This question is required.

2. Prescriber name: *This question is required.

3. Email: *This question is required. This question requires a valid email address.

4. Contact number: *This question is required.

5. Preferred method of contact for queries about a case? *This question is required.

Implant Component Ordering - Where implant components are required, wherever possible these are ordered directly onto your preferred impant provider account. To help us get things in place as quickly as possible, please provide your details below. If you are required to add Byrnes Dental Lab as an authorised party for orders, we'd appreciate you contact your provider to advise them. If this is not applicable to you, just click Next. Thanks.
(Please note: orders placed on our account may incur a 20% handling fee)

6. Implants - preferred provider: (if applicable)

7. Implants - account number: (if applicable)

8. Implants - account name: (if applicable)