Have You Co-Managed With a LASIK Provider Before?*

Were you a member of the LASIKPartners Program?*

Who Have You Co-Managed With Before?*

Other Brand

Doctor Email*

This MUST be a Unique Email to you specifically. Our CRM does not allow us to have more than one contact with the same email address.

Doctor Phone*

Practice Name*

Practice Email*

Practice Phone*

Practice Fax

Geographic Market (City)*

Practice Primary Contact Email*

Practice Tax ID #*

W9 Form (PLEASE SUBMIT IF WE DO NOT HAVE ON FILE)

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

How Did You Hear About This Program?*

Other

Co-Management Signup / Opt-in

Questions?