New Practice Program
To assist you in establishing your new practice and to make your first 5 years more successful, Mentor is pleased to offer you special product savings, patient education materials, and marketing and practice support. Please complete and sign this credit application in full to be considered for open account status. If the information supplied is incomplete or found to be incorrect, this may delay processing of the application and could affect prompt delivery of products or services. In addition, inaccurate information may void your eligibility for participation in this program. I, (We) submit the following information in applying for an open account: (required info)
Participation in this program is subject to eligibility criteria and Mentor's acceptance of your application.

Physicians are eligible once in a lifetime and must have received a new Mentor bill-to account number. Breast Implants are not redeemable for cash, and are non transferable. Eligibility expires five years after the sign-up date.

Eligible products, services, and pricing are subject to change. All non-consignment orders will be entered as Easy Orders by default. Mentor Easy Order form not required.

1.Easy-Order Request: All products ordered through the Easy-Order Program are subject to the terms of this Agreement and Mentor's standard invoice terms. If a Purchase Order Number ("P.O.") is required for billing, the P.O. must be provided at the time of order.
2.Easy-Order Product Return: Customer agrees to return to Mentor all unused products ordered through the Easy­ Order Program immediately after surgery. Unused products must be received at Mentor's Coppell, TX distribution center within 30 days of the Easy-Order shipment date.
3.Billing: Customer shall be invoiced for all items not received by Mentor within 30 days from the initial Easy-Order shipment date from Mentor to Customer and for any items that when received are destroyed, damaged, or otherwise not in saleable condition, and Mentor or its affiliate will retain title to those items. If a P.O. is required by Customer for payment, Mentor will reference the P.O. provided at the time of order on the invoice.
4.Payment: Customer agrees to pay all invoices resulting from an Easy-Order billing within Mentor's standard payment terms.
5.Term/Termination: This agreement becomes effective upon the date of Mentor signature and will remain effective indefinitely unless terminated by either party. Either party may terminate this agreement, with or without cause, upon fifteen (15) days written notice to the other party. Upon termination of this agreement, all outstanding products ordered through the Easy-Order Program would be immediately invoiced to Customer.

This site will only collect, use, and disclose information you submit here as necessary to fulfill your requests or as disclosed here. You agree that your information will be governed by our Privacy Policy. More information on Mentor's New Practice Program can be found here.
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Signature & Registration

Sign this form by entering your email address and check the below box. Your signature on this form confirms your authorization for Mentor Worldwide LLC to keep this information on file.

By signing this form you certify that all information provided is complete and accurate. Your account will be activated upon approval of this application and the email address you provide will be your username. Once your application is approved you will receive a welcome email with login instructions.

I give permission to Mentor to run my credit and enroll me into the New Practice Program.  

Entering the above information and checking this box is your electronic signature. By this signature, you are agreeing to the foregoing terms and conditions of the New Practice Program.

If representations made by the buyer in this credit application are subsequently found incorrect or incomplete, the right is reserved to reject the application and to negate any obligation to proceed with any merchandise, and to bill buyer for the full value of any products and services previously provided under this program. (1) Buyer recognizes seller’s terms as stated on its invoice and acknowledges and authorizes a service charge of 1-1/2% per month (18% annual) on any past due amounts. (2) Seller shall have the right to (A) declare the entire amount due, (B) in the event of default customer agrees to pay attorney and or collection agency fees not exceeding 25%, (C) to change the terms of the account from time to time (consistent with applicable law) to be effective not less than 30 days after given written notice, (D) to limit the amount of credit extended under this account or terminate the account, upon given written notice thereof; but seller may avail itself of the terms of this agreement until full payment of the entire balance with finance charge to date of payment has been received. (3) In submitting this application for credit, buyer authorizes seller to investigate his/her credit record.