Giving you more reasons to smile.

Account Authorization

The undersigned hereby applies for trade credit from Kelley Dental Laboratory, Inc. and agrees to the terms and conditions.

"*" indicates required fields

Name*

First Last

Practice Name*

Accounts Payable Contact*

First Last

Email*

Phone*

Fax

Address*

Street Address City State ZIP Country

Account Signature*

Bill To Account

Payment Date*

Monthly on the 1st

Monthly on the 5th

Payment Options*

Please debit payments from my Checking Account

Please charge my Credit Card

Checking / Savings Information

Routing Number*

Account Number*

Authorized Signature*

By typing in your legal name, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Date*

Credit Card Information

Card Type*

Visa

MasterCard

American Express

Credit Card Number*

Expiration Date*

Name on Card*

Verification Code*

Billing Address*

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

Signature*

By typing in your legal name, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Date*

Terms and Conditions*

Terms and Conditions: In consideration of Kelley Dental Laboratory, Inc. extending credit to Customer, Customer agrees to the following terms and conditions. Please complete and sign this form and return it to our Accounts Receivable Department. If we do not receive this form, any new cases will be billed on a C.O.D. basis until the Account Authorization form is returned.

Payment: Customer/Bill To Customer shall pay the statement balance on the 1st or the 5th of the following month. Any payment not received by the 20th will be subject to a 2% finance charge. Customer agrees this agreement is made in Floyd County, Indiana which is the proper venue for any action to collect money owed to Kelley Dental, Inc. by the Customer.

Limited Warranty: Kelley Dental Laboratory will repair or replace any restoration or prosthesis that fails due to defects in materials or workmanship, such as chipped or cracked porcelain, broken acrylic and/or a tooth falling out of removable appliance, within a period of one year from date of invoice.

Remake Policy: Kelley Dental’s goal is for you and your patient to be fully satisfied. If you are not, Kelley Dental Laboratory, will within 30 days from the day of invoice repair, adjust, change or replace your appliance to your satisfaction at no additional charge. All remakes within 30 days will be at no charge, except for remakes when the original RX slip has been modified including a shade change, a request for new models or impressions on the original case have been refused, a try-in has been refused or the teeth have been re-prepared. Remakes without the original case, will be remade at 100% of the retail price of the restoration at the time the request is made. There will be no cash refunds for custom dental restorations or prosthesis.

Refund Policy: The cost of fabricating custom dental restorations and prosthesis cannot be refunded. A credit may be issued by Kelley Dental Laboratory directly to a customer’s account when cases do not meet our expected standards for quality, function and aesthetics. Parts including implant components are not refundable unless the product can be returned to the manufacturer for credit.

I agree to the terms and conditions.

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