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.

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.
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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.  

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.