New Account Form

Please fill out the form below with your practice and billing information to open an account with us.

  • If not a BC customer, put "NA"
  • Statements will be sent to this email if opting in for email delivery below
  • We will send updates on pricing, products, etc.
  • If the company listed above has additional office locations, please fill out the section below. These are "Ship To" only addresses and will be billed to the Company and address listed above. If you have more than one location and require separate billing for each office, please fill out a separate NEW ACCOUNT REQUEST FORM for each office.
  • Payment Terms Net 30 Days. Statements sent out the first week of the month.