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Please enter the information below.

your personal details

Title

First Name *

Last Name *

Former Last Name

Email Address *

Cell Phone

Home Phone *

Office Phone

Fax

Date of Birth *

For identification purposes only

your address

Street Addr 1 *

Street Addr 2

PO Box

City *

Country

State

Zip Code

Selected Practice Location

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

Required for contact lens verification.

Practice name

Practice Phone

Practice 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. You may opt out of any emails you receive from our online store at any time.