Register Account

If you already have an account with us, please login at the login page.

Please enter the information below.

Your Personal Details

Title

*First Name

*Last Name

Former Last Name

*Email

*Home Phone

Cell Phone

Office Phone

Fax

*Date of Birth

For identification purposes only

Your Address

*Street Addr 1

Street Addr 2

PO Box

*City

*State

*Zip Code

*Country

Selected Practice Location

Password

*Password

*Confirm Password

How did you hear about our online store?

Employee Information

Name of Employee

Relation to Employee

Are you a patient of our practice? Required for contact lens verification.

Your Doctor

Your Optical Practice's Contact Information

Clinic Name

Office Phone

Fax

By clicking REGISTER you agree that we comply with all HIPAA regulations regarding your privacy. Our HIPAA Statement is available to you at any time under the Privacy Statement tab in our webstore.