New Customer Account Signup

If you are an existing customer and need to submit updates to your account profile, please click here.

Practice & Personnel Information

Name of Practice*

Do you have an Optometric Membership?

ALLDocs

Hoot

ODs on Finance

PECAA

Power Practice

TeamVision Essilor

Vision Source

Vision Trends

Other

If "Other", Please Specify:

Does your Account require PO# for orders?

Yes

Is your Account associated with the Military / Government?

Yes

Is your Account associated with a School / University?

Yes

Eye Care Practitioner

By law, Visionary Optics can only sell directly to a licensed doctor. We take every precaution before selling our medical devices for our protection and yours.

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Name of Practitioner

Name of Practitioner*

First Last

Credentials*

NPI/License #*

Email Address*

Phone Number*

Fax Number

Graduated within the last 12 months from an accredited School of Optometry.*

Yes

Please also view the new OD discounts offered on the New OD Program page

What year/month did you graduate?*

What school did you graduate from?*

Do you have additional Eye Care Practitioners?

Choose the amount of additional practitioners you'd like to add to your account below and then fill out their information.

Eye Care Practitioner 2

Name of Practitioner*

Credentials*

NPI/License #*

Email Address*

Phone Number*

Fax Number

Are you a Recent Graduate?*

Graduated within the last 12 months from an accredited US or Canadian School of Optometry. If yes, please also complete New OD Program

Yes

Eye Care Practitioner 3

Name of Practitioner*

Credentials*

NPI/License #*

Email Address*

Phone Number*

Fax Number

Are you a Recent Graduate?*

Graduated within the last 12 months from an accredited US or Canadian School of Optometry. If yes, please also complete New OD Program

Yes

Eye Care Practitioner 4

Name of Practitioner*

Credentials*

NPI/License #*

Email Address*

Phone Number*

Fax Number

Are you a Recent Graduate?*

Graduated within the last 12 months from an accredited US or Canadian School of Optometry. If yes, please also complete New OD Program

Yes

Additional User Information [optional]

This section can include information on other personnel; this could include office manager, technician, etc.

Name

First Last

Email Address

Phone Number

Fax Number

Do you have additional Users to add?

Choose the amount of additional users you'd like to add to your account below and then fill out their information.

Additional User 2 Information

Name

First Last

Email Address

Phone Number

Fax Number

Additional User 3 Information

Name

First Last

Email Address

Phone Number

Fax Number

Additional User 4 Information

Name

First Last

Email Address

Phone Number

Fax Number

Shipping Information

You will be able to add alternate shipping addresses once your new account has been created.

Attention To

Optional

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Preferred Shipping Default Method*

We use UPS as our primary shipping carrier. For International shipments, contact our Customer Service Department for Shipping Options

Ground

3rd Day

2nd Day

Overnight

Other

Alternate Shipping Email Address [optional]

Shipping notifications can be sent to this alternate address, when applicable.

Billing Information

Is your Billing Address same as your Shipping Address?*

Yes

Attention To

Optional

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Enroll in our Monthly Autopay Program*

If Yes, we will contact you with more details and to complete an Authorization Form.

Yes

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Billing Email Address*

We will send all Billing-related correspondence to this email address.

Billing Email Address*

We will send all Billing-related correspondence to this email address.

Billing Phone Number

Optional

Scleral Lens Fitting Journey*

Which description matches you the best in terms of your scleral lens fitting journey?

Newcomer - You are new(er) to scleral lenses and looking to get started.

Seeker - You are currently fitting scleral lenses but would like to increase your confidence and efficiency a bit more.

Optimizer - You love fitting scleral lenses but need to figure out how to streamline the process.

Expert - You are an experienced fitter who likes to take advantage of the most advanced customization options available.

Myopia Management (Ortho-K)

Are you interested in starting or expanding the myopia management segment of your practice?

Euclid’s system is set up to be easily implemented in both the experienced and novice Ortho-K practices with its efficient empirical fitting philosophy (no upfront investment for a trial set needed!) and high first fit success rate of 87%. Visionary Optics joined forces with the Euclid Vision team.

If yes, we will contact you with more information.*

Yes

Stay in Touch

How did you find out about us?*

Colleague Referral

Pt. wearing your lens design

Euclid Referral

Industry Meeting

VibrantVue® Interest

Email/Internet Search

Other

Referral Name*

First Last

Referral Email*

Euclid Referral Name

Meeting Name*

Other Details*

Send me the latest news from Visionary Optics*

Yes

Comments

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