SCD Application/Sign Up Form | Southern Cross Dental

Personal Information

Full Name*

AHPRA NO. DEN*

Previous SCD Account Holder

Previous Southern Cross Dental Account Holder

Postal Address

Street Address*

Add Address Line 2

Address Line 2

Suburb*

State*

Postcode*

CAPTCHA

Surgery Details

Surgery Name*

Surgery Email Address*

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Surgery Phone Number*

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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*

Surgery Address

Same as postal address

Use different surgery address

Street Address*

Add Address Line 2

Street Address 2

Suburb*

State*

Postcode*

Surgery Contact

Contact Name*

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Contact Position*

Business Information

Business Trading Name*

This business belongs to a corporate group

Corporate Name

ABN*

Additional Notes

Add Promo Code?

Promo Code

Condition*

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

Condition*

I am the owner of the account or legally authorised to open an account on behalf of the owner

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.