APPLICATION FOR AN IVODENT ACCOUNT
Practice Information
Private Company
Public Company
Close Corporation
Partnership
Sole Trader
*Nature of Business/s
DIGITAL DENTIST
DENTIST / CLINICAL
DENTAL THERAPIST
DENTAL ASSISTANT
E4D USER
EAR NOSE AND THROAT SURGEONS
GENERAL PRACTITIONERS
INDEPENDANT PHARMACY
DENTAL LAB
DIGITAL LAB
MAXILLOFACIAL SURGEON
ORAL HYGIENISTS
ORTHODONTIST
PERIODONTIST
PHYSIOTHERAPISTS
PROSTHODONTISTS
ENDODONTIST
LEADS DENT JOURNAL
IVOHEALTH CONSUMER
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*Practice Focus Areas
DIGITAL / CADCAM DENTISTRY
DIGITAL / CADCAM LAB
GENERAL DENTISTRY
COMMUNITY DENTISTRY
ORTHODONTICS
ORAL HYGIENIST
EAR NOSE THROAT SURGEON
MAXILLOFACIAL SURGEON
ENDODONTICS
ORTHODONTISTS
PERIODONTICS
PROSTHODONTIST
PROSTHETICS
PAEDIATRICS
AESTHETICS
IMPLANTS
LASERS
GERIATRICS
SPECIAL NEEDS PATIENTS
RADIOLOGY
ORAL MEDICINE
E-mail debtors@ivodent.co.za with copy of practice registration or copy of recent BHF payment receipt.
Premises Owned by Applicant
Yes
No
Billing Address of Practice
*Country
Afghanistan, Islamic State
Albania
Algeria
American Samoa
Andorra, Principality of
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia, Kingdom of
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
Former Czechoslovakia
Former USSR
France
France (European Territory)
French Guyana
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe (French)
Guam (USA)
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong, Province of China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast (Cote D'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique (French)
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia (French)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Polynesia (French)
Portugal
Puerto Rico
Qatar
Reunion (French)
Romania
Russian Federation
Rwanda
S. Georgia & S. Sandwich Is.
Saint Helena
Saint Kitts & Nevis Anguilla
Saint Lucia
Saint Pierre and Miquelon
Saint Tome (Sao Tome)
Saint Vincent & Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
USA Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (USA)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
--None--
Delivery Address of Practice
Tick box to copy billing address
*Country
Afghanistan, Islamic State
Albania
Algeria
American Samoa
Andorra, Principality of
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia, Kingdom of
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
Former Czechoslovakia
Former USSR
France
France (European Territory)
French Guyana
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe (French)
Guam (USA)
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong, Province of China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast (Cote D'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique (French)
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia (French)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Polynesia (French)
Portugal
Puerto Rico
Qatar
Reunion (French)
Romania
Russian Federation
Rwanda
S. Georgia & S. Sandwich Is.
Saint Helena
Saint Kitts & Nevis Anguilla
Saint Lucia
Saint Pierre and Miquelon
Saint Tome (Sao Tome)
Saint Vincent & Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
USA Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (USA)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
--None--
Practice Contact Information
Primary Member Contact Information
*Designation/Title
Admin / Accounts Manager
Business Manager - Practice
Cosmetic Dentist
Dental Assistant
Dental Therapist
Dentist
Endodontist
Ear Nose Throat Surgeon
Lab Owner
Lab Technical
Procurement Manager / Buyer
Maxillo Facial Surgeon
Medical Doctor
Marketing Manager
Oral Hygienist
Oncologist / Radiotherapist
Oral Hygienist
Orthodontist
Peadiatric Dentist
Periodontist
Practice Manager
Prosthodontist
Receptionist
Store Manager
*Salutation
Mr.
Mrs.
Ms
Dr.
Prof.
--None--
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