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*
Your Name
Your Name
Your Name
Name
Position
Email Address

“Sandy's Hydro Tilt has been safely delivered to No. 11 Greenhills Road, and everyone is so pleased to have it”

Maggie Gibson, Private Customer

“Thank you SO much for supplying us with our Careflex chair – it arrived this morning, and we have already sat the gentleman out in it”

Occupational Therapist, Stoke-on-Trent

“I just wanted to say thank you for squeezing a fourth client on the day for a seating assessment at such short notice, I really appreciated it”

Occupational Therapist, St Matthews Healthcare

“Could you please pass on some good feedback to Premiere Healthcare regarding the assessment visit”

Mr Armstrong-Sly – West Midlands OT

Seating

Competitive daily rental fees on a wide range of equipment.

Rentals

Shower/Commodes & Trolleys

Wheelchairs

Beds & Mattresses

Bariatric

Paediatric

Hoists

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