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Contact Details

First name: *

Last name: *

Email:

Phone:

Company Details

Company name: *

Survival-32 A/C No.:

Business type: * *

Name of principal dentist:

Principal dentist GDC number:

Billing Address

Street address: *

Street address 2:

Street address 3:

Postal code: *

City: *

Country: *

Phone no:

Billing contact:

Login Details

Email: *

Password: *

Confirm password: *

Dental Practice Registrations
By completing this registration, you, as the account holder, partner or director.

• Agree that all details given on this form are correct

• Understand that you are responsible for informing Survival-32 Ltd of any changes to this application throughout the period the account is open.

• Understand that you may be asked to provide supporting documentation such as a valid copy of photo ID

• Understand that failure to provide reasonable requested documentation may result in your account being temporarily restricted from ordering medicines

• Bear the responsibility for any unauthorised access to your account as a result of you providing your account details to a third party or failure to hold them securely

By registering, the ‘Principal Dentist/Principal Dentist GDC Number’ stated on the registration form above is authorising the purchase of medicines on the account and the ‘Principal Dentist’ acknowledges and understands that they are responsible for:
• All orders of medicines placed on this account

• Ensuring that any medicines are held in suitable conditions and in a secure location until administered

• Ensuring that suitable insurance cover is in place for the administration of medicines

You understand that medicines can only be sent to a verifiable business address of the account holder and that any request to make a change to the address for delivery will require verification. I/We have read and agree to be bound by Survival-32 Ltd’s Terms and conditions. I/We understand that the latest version of the Terms and Conditions will be available at www.survival-32.co.uk. I/We acknowledge that the account will be subject to a minimal order value detailed in the Terms and Conditions, and that a delivery charge will be applied if this is not met.

Personal Data - GDPR

This privacy notice sets out how Survival-32 Ltd as the data controller, collects and processes your personal information in relation to your account. Our privacy policy which can be found at http://survival-32.azurewebsites.net/privacy-notice sets out the detailed information on how we process your personal information. The personal information we are collecting, as set out in this form, will be used to check against professional registers.
How we will use your personal information and the legal basis for its use: We will use this information to fulfil the contract with you as well as to comply with our legal obligations.
Sharing your personal information: We will share your information with regulatory authorities where required to do so as well as where we are using third party contractors (i.e. couriers) or data processing services.
Retention: We will delete your personal data after six years from the date that you cease to be a customer unless legally required to keep it for longer.
By clicking REGISTER I agree to the above Terms and Conditions