New Customer Form | C2Dx

New Customer Form

Please fill out the form below.

Facility Name

Customer Billing Address

City

Zip

State

Country

Order Confirmation Email

Customer Shipping Address

City

Zip

State

Country

FedEx Account Number

Accounts Payable Name

Accounts Payable Email

Accounts Payable Phone

Email to Submit Invoices

Requesting Department

Contact Name

Contact Phone Number(s)

Contact Email(s)

If facility is part of a larger hospital system, please name here

Tax-Exemption Number

Please Upload Tax Exempt Form

Please Upload W9 Form

555 East Eliza Street | Ste. A
Schoolcraft, MI 49087

Fax 269.204.2480

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