Optometrist/Ophthalmologist Registration Form


Thank you for your interest in Eyefinity. Please complete the form below to apply for a personal Access ID and Password. All applicants will be notified by phone in three business days if approved.

Note: If you are a VSP doctor, you do not need to complete this form. Please call Customer Care at 877-448-0707 for your Access ID.
                                                       
Provider Information
First name*  Middle  Last name*  Suffix 
Title    (O.D., M.D., etc.) Tax Id*   
License #*    SSN*   
  Individual NPI* 
80840 
 
  Group NPI  
80840 
 
 
How did you hear about Eyefinity?*
Promotional Mailer
Received a Phone Call
Word of Mouth / Friend
Advertisement in Trade Publication (please specify)
Trade Show (please specify)
Other (please describe)
 
Are there other providers in this office who will use Eyefinity services?*
Yes (we will contact you to discuss administrative options)
No
 
Please indicate which best describes you:*
Ophthalmologist in a private practice
Optometrist in a private practice
Optometrist in a retail chain (e.g. Wal-Mart, Target, LensCrafters)
Other (please describe)
 
How many offices make up your practice?*
 
Are you a member of a state or national professional association/society?
Yes (please specify)
 
E-mail address:* (Eyefinity will not share your e-mail address or other information with any outside parties.)
 
Practice Information
Practice name* 
Phone number*  Fax number  
Employer ID number (EIN)  
Physical Address   Your physical address is required for shipping purposes when ordering products from our partners. They are unable to deliver to a P.O. Box.
Address line 1* 
Address line 2  
City*  State*  Zip code* 
Billing Address   All billing statements will be sent to this address. If this address is the same as your physical address, you may check this box to avoid retyping.
Address line 1* 
Address line 2  
City*  State*  Zip code* 
 
** A Credit Card number is required to register. Upon receiving your approval and your Access ID/Password, your card will be charged a one-time $79 registration fee. You will receive a mailed confirmation of the charge. In addition, your card will be used as collateral in the event that charges are incurred on the Eyefinity site and an alternate payment option is not established. For your convenience, charges can be automatically made using your credit card. Please ask our representative when we contact you with your Access ID and Password.  
 
Name on Card (exactly)* 
Billing Address for Card* 
 
City*  State*  Zip code* 
Card Type*  Card Number* 
Expiration Month*  Expiration Year* 
Promotional Code 
 
* Indicates a required field  
 
If applicants are found to be fraudulent or in unfavorable standing with any Eyefinity business partner, the membership request will be denied and the credit card will not be charged. Any denial notices will be sent by letter within seven to 10 business days.