Skip to main content

Account Setup Form

Please contact Boston Scientific US Customer Care @ 888-325-1060 if you have questions or need assistance completing this form.

General Information

Company Information

*Change if different from main facility address.

*For shipping address

*Please attach as a PDF file

*Please attach as a PDF file

Company Tax Information

*Please attach as a PDF file

Credit Information

Owners-Officers Information

*Please attach as a PDF file

Payment Information

*If payment is with credit card, please contact Boston Scientific Credit Dept @ 888-272-9442.

*Do not add credit card info into this field

If payment method is financing please provide:

Trade References

Company #1

Company #2

Company #3

Applicant Information

*Typed name is acceptable for electronic signature

Please allow 24-48 business hours after the form has been submitted for review. Additionally, Boston Scientific may contact the submitter of this form if additional information is needed.

By signing above, you are attesting that you have the appropriate authority to execute this application on behalf of the applicant, and that the information herein is complete and accurate. Furthermore, you are hereby authorizing Boston Scientific to use all information you enter onto this form to process your application, carry out contract, support, payment and related activities, if applicable, and use this information for additional purposes identified in its Privacy Policy. You are also authorizing Boston Scientific to share information contained in this application with its subsidiaries, affiliates, successors and assigns. This application is subject to Boston Scientific’s credit policy, and Boston Scientific at its sole discretion may elect to refuse or to extend credit, or to limit the amount of credit extended.

This agreement and performance by the parties hereunder shall be construed in accordance with the laws of the state of Delaware, USA, without regard to provisions on the conflicts of laws and the parties’ consent to the exclusive jurisdiction of, and venue in, the State and federal courts of Massachusetts.

Boston Scientific reserves the right to charge interest on any amount not paid when due at the maximum rate permitted by applicable law.

The applicant agrees to reimburse Boston Scientific all fees and costs Boston Scientific incurs while seeking legal remedies to protect or enforce its rights under this agreement, including fees associated with collection of any past due payment and agency fees.