Myzecare Partner Registration Form

myzecare™ Provider Registration Form
Official Registration Information
Provider Name or Practice Name (this should be the official name for your registration)*

First Name (if signing up as an individual doctor) ~ Practice Name (if signing up as a practice)Last Name (if signing up as an individual doctor) ~ Practice Type ie:PLLC (if signing up as a practice)
Your Name*
If you are a provider registering for yourself, please re-type your name.
Your Email*
example@example.com
Mobile Number (optional)
Please enter a valid mobile phone number to opt in for us communicate directly with you.
Type of Doctor (if signing up as an individual doctor)*

MDODDOSigning up as a practice
How did you hear about us?*

Peer RecommendationSocial MediaProfessional ConferenceOther (please specify)
Practice Information
Practice Name*
Number of Doctors in the Practice*
Street Address *
Street Address 2
City*
State
Zip Code*
Practice Type*

Comprehensive OphthalmologyOptometryRetinaCombination
Office Manager/Practice Contact
Office Email
example@example.com
Office Phone Number*
EMR System*
Practice Website
How do you communicate with your patients? (check all that apply)*

EmailTextPhone
Product and Procedure Information
Approximately what percentage of your patients have dry eye and/or blepharitis?*
Type the number only
Do you sell OTC products in your office?*

YesNo
If so, which products?
Does your office provide any of the following procedures? (check all that apply)

Aminiotic MembranesPunctal PlugsScleral LensesIPLRadio FrequencyILuxTearCareLipiflowZESTBlephExSerum TearsLow Level Light TherapyGland Probing
Does your office offer any cosmetic services?*

YesNo
If so, which services? (check all that apply)

Botox or other NeuromodulatorsFillersFacials/Peels or other Aesthetic ServicesRF of FaceRF of BodyEmSculptMicro NeedlingAesthetic LasersOther (please specify)
myzecare™ Partner Storefront Details
Headshot (Please upload a current headshot for us to include on your storefront)

Acceptable formats are jpg, jpeg, png
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Which myze routines and products would you like to feature as your recommended items on your storefront?

eyetamins Dry Eye Comforteyetamins Vision Supporteyetamins blue blocker gummiesThe Dry Eye Drink - Mixed Berry FlavorThe Dry Eye Drink - Orange FlavorThe Dry Eye Drink PM - Orange Flavormyze Plus RoutineOPTASE Moist Heat MaskOPTASE Dry Eye Intense DropsOPTASE Dry Eye SprayOPTASE HYLO Night Eye OintmentOPTASE MGD Advanced Preservative Free Dry Eye Dropsmyze Total TTO RoutineiVIZIA Preservative Free Dry Eye DropsiVIZIA Dry Eye Night Gel Single Use Vials
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myzecare™ Provider Registration Form

Official Registration Information

Practice Information

Product and Procedure Information

myzecare™ Partner Storefront Details