Purchasing Agreement: Modern Dental Laboratory

PRACTICE INFORMATION:
Practice Name (required)

Name of Primary Dentist (required)

Name of Employee Responsible for Lab Orders (required)

Email of Employee Responsible for Lab Orders (required. Will receive auto confirmation email for next step.)

State (required)

Do you currently send lab cases to Modern Dental Laboratory? (required)
—Please choose an option—YESNO

Instructions for the Cooperative: (optional)

TERMS AND CONDITIONS OF PARTICIPATION
To qualify for the Dental Cooperative negotiated volume discount pricing with our vendor partner, participants must meet the following criteria:
• Participants must be a current member of the Dental Cooperative in good standing.
• All associated items subject to discount must be purchased through the identified sales channels as specific above.
• Discount pricing structure begins only after agreement has been received and processed by the Dental Cooperative and vendor partner.
• Upon termination from the Dental Cooperative, Member will no longer have access to discount pricing defined in the terms.
• Signing this document permits Modern Dental Laboratory to transition your current account to the Dental Cooperative group account.
• Additional program details and terms are available on Member Services.
I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent (required)

Date Agreement Signed MM/DD/YYYY (required)

IMPORTANT! Once submitted, you will immediately receive an email to the address you indicated on this form. This email contains important information for the next step to register at Modern Dental Laboratory. Soon after, you will also receive confirmation emails from the Cooperative for enrollment and your assigned vendor rep with their contact information.