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customer registration

Print Registration

If you would prefer, you can print and fill in our registration form and send it by fax to 01243 555197 or post it to ArosChem UK Ltd, Unit 7, Ford Lane Business Park, Ford Lane, West Sussex, BN18 0UZ

Print PDF registration form / Print Word registration form

Online Registration

Please take time to fill in the form below. Fields marked with an asterix are compulsory.

Please note we only supply to registered dentists and not to the general public.

Once we have verified that we can supply to you, you will be assigned a customer account number and password which will be emailed to the email address you supplied allowing you to order goods online.

Please only supply your practice phone number and not a mobile phone number.

Assignment of Account No. and Password should take under 24 hours depending on time of application.

Contact Details
First Name* Last Name*
Email* Telephone*
Fax Key Contact Person
Practice Details
Practice Name* Address 1*
Address 2 Address 3
City* County
Country* Post Code*
Delivery Address (if different from above)
Practice Name Address 1
Address 2 Address 3
City County
Country Post Code
Security Question
GDC no.*
Miscellaneous
How did you find us
Comments

Please enter the code to complete the registration

note: if the code is entered correctly, after you click "go" you will see a green tick on the next page, if the code was incorrect you will be brought back to this page to fill in your details again.

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