New Customer Registration

Business Entity Information

Business Name(Required)

Business Entity Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

FEIN Number(Required)

Is this a Government Entity?(Required)

Are You Tax Exempt?(Required)

If tax is NOT APPLICABLE, a tax exemption certification must be supplied as well as an exemption number. It is the responsibility of the customer to ensure that all the necessary documents are supplied otherwise, tax will be charged.

Tax Exemption Number(Required)

Tax Exemption Certificate(Required)

Accepted file types: pdf, Max. file size: 2 GB.

Please Upload W9(Required)

Accepted file types: pdf, Max. file size: 2 GB.

Invoice Information

Invoice Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Invoice Contact Name(Required)

First Last

Contact Email(Required)

Contact Phone(Required)

Email Address for Invoices(Required)

Invoice Portal Address

Please provide any special invoicing instructions

Accounts Payable Information

Accounts Payable Contact Name(Required)

First Last

Accounts Payable Email(Required)

Accounts Payable Phone(Required)

Delivery Information

Delivery Business Name(Required)

Delivery Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Delivery Contact Name(Required)

First Last

Delivery Contact Email(Required)

Delivery Contact Phone(Required)

If Multiple Delivery Addresses, Please Upload Here:

Accepted file types: pdf, Max. file size: 2 GB.

IT and User Admin Information

* Information required if you have purchased Metrasens Vantage with Metrasens IQ.

Did you purchase Metrasens Vantage with Metrasens IQ?(Required)

Yes

Hospital IT Contact Name(Required)

First Last

Hospital IT Contact Email(Required)

Hospital IT Phone(Required)

Metrasens IQ Administrator Name(Required)

First Last

*Typically imaging supervisory role

Metrasens IQ Administrator Email(Required)

Metrasens IQ Administrator Phone(Required)