Practice Name(Required)

Practice Address (Primary)

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

Practice Email

Practice Phone(Required)

Practice Fax

Practice Primary Contact Name

First Last

Primary Contact Email

Primary Contact Phone

Have you co-managed with a LASIK practice before?(Required)

Yes

No

How DId You Hear About This Program?

This field is hidden when viewing the form

What best describes your scope of practice?

Private practice, single location

Private practice, multiple locations

Retail practice

This field is hidden when viewing the form

Services I'm Interested In

Offering LASIK & SMILE Pro

Offering ICL & Refractive lens exchange

Offering Cataract surgery

Recieve new patient referrals for routine care

Recieve new patient referrals for post-operative care

Check all of the services you are interested in offering.

This field is hidden when viewing the form

Are you interested in co-managing care?

Yes

No

Join Our Partner Network

Physician Partnership Application