Test Environment
New Practice Account
New Practice Account Form
*Practice Name (D/B/A):
Legal Practice Name:
Primary Location
*Country:
United States
Canada
*Address 1:
Address 2:
*City:
*State:
AB
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UM
UT
VA
VA
VI
VT
WA
WI
WV
WY
YT
*Zip Code:
Products Requested
BostonSight SCLERAL D 16-17mm
BostonSight SCLERAL E 18-19mm
BostonSight SCLERAL Smart360
Do you currently use a topographer for empirical/image-guided fitting?
OCULUS PentaCam CSP
Eaglet Eye Surface Profiler
Other
* I agree to BostonSight's
Terms and Conditions of Use
* I understand that the practice administrator is responsible for periodically reviewing and confirming all account information, including practice group members
Are you a licensed contact lens prescriber?
Yes
No
Message
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