Create New Customer Account

Registration is limited to US customers only. Please fill in every field marked with an “*” to request registration.

First Name

Last Name

Legal Name

Job Title

Facility/D.B.A. Name (if applicable)

Password

Password Strength: No Password

Confirm Password

Fax Number

GPO affiliation

Premier

HealthTrust (HPG)

Vizient (Novation/MedAssets)

Other

DSO affiliation

Please provide the last (4) digits of credit card you want saved to your account and used for all future web orders

After your account registration has been submitted, our Customer Experience Team will contact you to verify your credit card information which will be set as your default payment method for all orders placed via the LifeNet Health Dental Store. Each time you place an order, you will be asked to review the last (4) digits of your default credit card and approve the transaction. For security purposes, only the last (4) digits of your credit card will appear in your records.

Primary Address

Facility Name

Phone

Street

Country

State/Region

City

Zip Code

Shipping Address

Same As Primary Address

Facility Name

Phone

Street

Country

State/Region

City

Zip Code

Billing Address

Same As Primary Address

Facility Name

Phone

Street

Country

State/Region

City

Zip Code

Primary Contact

First Name

Last Name

Job Title

Telephone

E-mail Address

Secondary Contact

First Name

Last Name

Job Title

Telephone

E-mail Address

Accounts Payable Contact

First Name

Last Name

Job Title

Telephone

E-mail Address

Upload W-9 form

By signing up, you are creating a LifeNet Health account, and you agree to the LifeNet Health Terms of Use and Privacy Policy.