U.S. Customers: Please fill out the form below to receive a DePuy Synthes Account number. 
Only licensed veterinarians treating animals can become a DePuy Synthes Vet customer.
You will receive notification that your account has been set up in up to 7-10 days.
If you have any questions about this form, please call Customer Relations at (800) 523-0322.

Outside of the U.S., please contact your nearest DePuy Synthes country office.

NEW ACCOUNT REQUEST
Phone Number: 800-523-0322

Account Information
* = Required Field

Note: New account set-up may take up to seven business days for review and approval.
*Practice Name: Practice Website:
Type of practice: # Surgeons treating orthopedics:
*Primary Veterinarian's First Name:   M.I. *Last Name
*State Veterinary License Number:   *State Issued:

Is this facility a private practice?   If Yes:
*Name of financially responsible party:
First: Last:
Bank Authentication Form

Is your facility tax exempt?
(If yes, please fax a copy of the tax-exempt certificate.  Law requires that a copy of the tax exemption certificate be on file prior to an order being processed.)
BILLING ADDRESS:
*Billing Address: *Phone:   ex. (555) 765-3421
Billing Address: Fax:
*City: *State:  *Zip: *County:

SHIPPING ADDRESS: Copy from Billing
*Shipping Address: *Phone:   ex. (555) 765-3421
Shipping Address:   Fax:
*City: *State:  *Zip: *County:

Are you a mobile veterinarian?
Is this facility associated with a Buying Group?
(If yes, Buying Group info needs to be filled out)
BUYING GROUP INFO:
*Buying Group Name:
*Address:
Address:  
*City: *State:  *Zip:

Is this facility associated with a Parent Account?
(If yes, Parent Account info needs to be filled out)
PARENT ACCOUNT INFO:
*Parent Account Name:
*Address:
Address:  
*City: *State:  *Zip:

Contact Information
*Primary Contact Person: *Title: *Phone: *Email:
Secondary Contact Person: Title: Phone: Email:

Is there an order pending?
(If yes, please fax a hardcopy of your purchase order)

* = Required Field
By signing this application, I agree that the statements in this application are true and complete, and will inform DePuy Synthes
Vet in writing of any changes to address, telephone number or financial condition of the applicant.
First Name: Last Name:
DePuy Synthes Terms and Conditions