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

Full Name*

Dental Council of NZ registration number*

Previous SCD Account Holder

Previous Southern Cross Dental Account Holder

Street Address*

Add Address Line 2

Address Line 2

Suburb*

Postcode*

CAPTCHA

Surgery Name*

Surgery Email Address*

Surgery Phone Number*

Have you had an account with SCD before?

If yes, what was your account number?

Does anyone at the surgery currently have an account?

If yes, what is their account number?

Principal Dentist Name*

How have you heard about SCD NZ ?

Same as postal address

Use different surgery address

Street Address*

Add Address Line 2

Street Address 2

Suburb*

Postcode*

Contact Name*

Contact Position*

Business Trading Name*

This business belongs to a corporate group

Corporate Name

NZBN*

I am a director/ trustee of the company/trust listed

Additional Notes

Add Promo Code?

Promo code

By creating an account, you agree to scdlab’s website Terms and Conditions and Privacy Policy .

Condition

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.