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New customers

World Dental Relief requires verification from the dentist, physician or clinic requesting supplies that the cooperating organization or church is a faith-based, charitable 501(c)3 organization or church before supplies will be shipped.

World Dental Relief reserves the right to refuse to ship dental supplies to any group which has not provided these or met these required certifications.

In order to request a customer ID and password, please complete the following information. Your request will be reviewed on the next regular business day. If you meet all the qualifications for requesting supplies, you will receive an email with your ID and password.
* required
Name of Individual or Clinic: *
Name of Dentist or Physician: *
Dental / Medical License #: *
State/Country of Licensure: *
License Expiration Date: * (mm/dd/yyyy)
DEA #:
DEA Expiration Date:  (mm/dd/yyyy)
Please Fax, Email, or Mail a copy of the license and DEA form for our records.
Contact Information
Email Address: *
Confirm Email Address: *
Phone: * Ext:
Alternate Phone:
Project Information
Charitable Organization or Church: *


City, State, & Zip: *   *   *
Contact Name:
Contact Phone:
Organization/Church Website:
What type of project is this?
Please give us a brief description of your project:
Name of Country (or countries) visiting: *

Date of trip(s):

Dates only please! If there is no specific date, please leave the field blank.

1st:  (mm/dd/yyyy) Enter start date of trip only!

2nd:  (mm/dd/yyyy)

Date supplies are needed before your trip departs:  (mm/dd/yyyy) Please DO NOT put "ASAP"
Billing Information
Select one for BILLING address: Business Residence
Address: *
City, State, & Zip: *   *   *
Shipping Information              We are not able to ship to PO Boxes!
Shipping address is the same as the Billing address.
Select one for SHIPPING address: Business Residence
Address: *
City, State, & Zip:      
Don't put anything in the following field:
Create a UserName: *(8-15 characters)
I have read the policy guidelines and accept responsibility for the proper use of these relief supplies.


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