Subscription Request

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Business Profile:

Please check if you are:

Years In Practice:

Please check your professional/business status:*

If Other, please specify

If Optometric Student, please check year of school

Which of the following do you buy, specify or influence the purchase of: (check ALL that apply)

22 - Spectacle Lenses
23 - Instruments & Equipment
24 - Contact Lenses-Solutions
25 - Pharmaceuticals

How many of the following do you prescribe/dispense in an average week? (Please provide #):
Ophthalmic Lenses

Contact Lenses

Rx Prescriptions

What is the approximate annual sales volume at your business?

Do you currently co-manage surgical patients?

YesNo

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