New Customer Account Form

If you are interested in becoming a new Blink Medical customer, please fill out the form below with your details.
Please note: Your first order may be subject to a proforma payment.

Full Legal Company Name:
Invoice Address:
Post Code:
Telephone Number:
Fax Number:
Web Address:
You are a: Limited Company Sole Trader Partenership NHS
Company Registration Number:
Please give details:
Delivery Address if different
to invoice address:
Contact Name:
Contact Telephone Number:
Contact Email:
Please fax a copy of your company letterhead to: 0121 277 4949
Or post to: Blink Medical Ltd,
1320 Solihull Parkway,
Birmingham Business Park,
B37 7YB