New Account Application

Practice Demographic Info

If you have multiple locations will you want separate accounts for each?
* Dental Practice Structure?
* Text Message Options
J&L employs Easy Text through our main phone line 585-475-0160 for Supply Orders, Service or IT Issues or any general Customer Service Inquiries. In compliance with federal text message guidelines we need permission to text you. We do not use our text system for marketing purposes. We will occasionally use it for short-term notifications that effect your business, for example weather related closure or changes to business hours.

Billing / Accounts Payable

* Invoice Delivery Options
If different from AP Email address listed above
* Do you require PO numbers for all invoices?
* Automatic Payment Options
Please select the method your prefer for for automatic payment by credit card. Please call 585-475-0160 and ask for accounting to add your credit card to your account. All credit card information is encrypted and used in compliance with PCI standards. If you would prefer terms on your account please call 585-475-0160 to request a credit application.
* Are you tax exempt?
* Would you like to use your own UPS account for shipping?

Professional License Info

Additional Information

Would you like access to our Service Portal

Contact Information

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