Representative

Mark Nordyke (General)

Richard Huynh (General)

Laura Carey (Lens Orders)

Felicia Tran (Insurance)

Name *

First Name

Last Name

ALL CUSTOMERS RECEIVE PAPER STATEMENTS. WOULD YOU ALSO LIKE TO RECEIVE E-STATEMENTS?

Yes

No

IS YOUR BILLING ADDRESS AND BILLING CONTACT PERSON THE SAME AS YOUR PRIMARY BUSINESS INFORMATION?

Yes

No

WOULD LIKE TO BE CONTACTED BY OUR ACCOUNTING DEPT. TO SETUP AUTO-PAY OR REVIEW ANY OTHER BILLING QUESTIONS?

Yes

No

WHAT SOFTWARE ARE YOU CURRENTLY USING TO ORDER ONLINE?

VisionWeb

DVI/RX Wizard

Not Ordering Online

ONCE YOUR ACCOUNT IS SET UP DO YOU REQUIRE ANY OF THE FOLLOWING?

SHIPPING LABELS

PAPER ORDER FORMS