Add to Brochure

New Customer Account Form US

Build a Brochure

Start a custom brochure with the help of our new Brochure Builder Tool.

While browsing remember you can add any page to the brochure builder by clicking on the button labeled + add to brochure located at the top of each page

If you are not a current Smiths Medical customer, please complete and submit the form below to setup an account. To expedite your account setup, please respond to all of the following questions with accurate information. 

Please note: You will need to complete and upload either the Authorization for Medical Directors and Pharmacists in Charge License Form or the Wholesale Distributor Authorization Form in order to submit your application.  

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New Customer Information
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Please Describe Your Organization
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Is your organization a member of any of the following purchasing groups? Please select all that apply:








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Billing Address
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Shipping Address
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Purchasing
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Will This Be A One-Time Purchase:
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Is Your ERP System EDI Compatible
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State license requirement: Please complete the appropriate form. Failure to do so will result in your application being denied.
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New Customer Account Credit Application
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Trade References
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Trade References
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Trade References
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Bank Reference
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Application Consent
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