SCD Application/Sign Up Form - Southern Cross Dental New Zealand

Personal Information

Dental Council of NZ registration number*

Lookup DCNZ

Full Name*

I'm not a dentist

If not a dentist, please select the option below:*

Preferred name

Dentist Email*

Does your practice belong to a Corporate Group?

Yes

No

Which Corporate group do you belong to?*

Other Corporate group

Are you responsible for payment of invoices with SCD?

Yes, I am

No, payment managed by Head Office

Trading Name*

NZBN*

Lookup New Zealand Business Number

Have you had an account with SCD before?

I already have an account with SCD in the past

If yes, what was your account number?

CAPTCHA

Practice Details

Practice Name*

Practice Address*

Practice Address 2

Suburb*

Town/Region*

Postcode*

Is your Delivery Address different to your Practice Address?

Postal Address*

Postal Address 2

Suburb*

Town/Region*

Postcode*

Practice Phone*

Practice Contact Name

Position

Digital Scanners

Trios

CS-Connect

Sirona-Connect

iTero

MeditLink

DEXIS

Other

How to connect your scanner with SCD

Please Mention*

Add Promo Code?

Promo Code*

I wish to receive marketing & promotional material from SCD

I would like to join the Digital Cash Rebate* rewards program. I agree to the terms and conditions applicable.

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Personal Information

Practice Details