Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Lens Brands Used *

Varilux

Zeiss

Hoya

Shamir

IOT

Unity

Neurolens

Other

AR Treatment Brands Used *

Crizal

Zeiss

Hoya

Shamir

TechShield

Other

Order Entry and Style

Vision Web

DVI RxWizard

SpecCheck

Phone/Fax

Managed Vision Care Participation *

VSP

Eyemed

Versant/Davis/Superior

None

Other

Preferred Payment Method *

Credit Card *fee may apply

ACH

Check

Tax Exempt *

(Sales tax will be charged unless tax exempt form is submitted to the lab)

Yes

No

Next Steps *

I am ready to order! Independent may run a credit check in order to setup my account.

I would like to receive a partnership proposal.

Credit Check Authorization- Type the Name of an Owner or Officer *

By typing my name, I hereby certify that the above information is true. Independent Vision is authorized to obtain credit information relating to our business and bank accounts. I understand that should attorney or collection efforts be necessary; all reasonable attorney and collection fees will be paid by the customer. I understand the terms and conditions set forth and my personal guarantee of buyer’s obligations.

First Name

Last Name