Customer Set Up Form

Please fill out the form below to enable us to set up your account.

Please note that this form allows us to set up your customer profile. It ensures we have accurate and up to date details so we can fulfil your quote and deliver goods and services to you efficiently.

Any information we capture with this form will be processed in accordance with our Privacy Policy.

If you have an official quotation, please enter the reference below:
Company Name
Company Name
Billing Address
Address Line 1 Address Line 2 City ZIP / Postal Code
Company Registration Number
VAT Number (if applicable)
Order Placing
Order Queries - Contact Name
Order Queries – Contact Telephone Number
Order Queries – Contact Email Address
Invoicing
Email address where we should send invoices to
Address
Street Address Address Line 2 City ZIP / Postal Code
Accounts Payable – Contact Name
Accounts Payable – Contact Telephone Number
Accounts Payable – Contact Email Address
I hereby confirm that I am duly authorised to transact on behalf of the company detailed in section 1 of this form. I accept in the event of conflicting terms Premiere Healthcare Limited’s terms and conditions shall prevail.
Business terms & conditions
Rental terms & conditions
Deliveries & Returns

Premiere Healthcare trade credit terms are subject to status. Any trade credit terms we may offer will be advised once we have processed this form.
Signature*
Name
Position
Email Address

“We have had incredibly positive feedback from everyone who attended the service development training, and colleagues finding the learning pods really useful and informative”

Occupational Therapy Team Lead, Wye Valley NHS Trust

“Andrew, I can’t thank you enough for the excellent, person centred and flexible approach you have provided for my client, you have been nothing short of excellent”

Wiltshire OT

“First of all, I would like to express my deepest appreciation to you and your company for both your support and understanding of a very difficult situation that I am dealing with whilst trying my best to support Joyce with, whilst aiming to improve both the quality of her health and her life”

Private Customer – East Midlands

Seating

Competitive daily rental fees on a wide range of equipment.

Rentals

Shower & Commodes

Wheelchairs

Beds & Mattresses

Bariatric

Paediatric

User Needs

Account Application

Customer Set Up Form

Company Name

Order Placing

Invoicing

If you have any questions about our products or services, please get in touch

We operate within a 100-mile radius of our Tewkesbury HQ