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)
*
MD
OD
DO
Signing up as a practice
How did you hear about us?
*
Peer Recommendation
Social Media
Professional Conference
Other (please specify)
Practice Information
Practice Name
*
Number of Doctors in the Practice
*
Street Address
*
Street Address 2
City
*
State
Zip Code
*
Practice Type
*
Comprehensive Ophthalmology
Optometry
Retina
Combination
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)
*
Email
Text
Phone
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?
*
Yes
No
If so, which products?
Does your office provide any of the following procedures? (check all that apply)
Aminiotic Membranes
Punctal Plugs
Scleral Lenses
IPL
Radio Frequency
ILux
TearCare
Lipiflow
ZEST
BlephEx
Serum Tears
Low Level Light Therapy
Gland Probing
Does your office offer any cosmetic services?
*
Yes
No
If so, which services? (check all that apply)
Botox or other Neuromodulators
Fillers
Facials/Peels or other Aesthetic Services
RF of Face
RF of Body
EmSculpt
Micro Needling
Aesthetic Lasers
Other (please specify)
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myzecare™ Partner Storefront Details
Headshot (Please upload a current headshot for us to include on your storefront)
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Which myze routines and products would you like to feature as your recommended items on your storefront?
eyetamins Dry Eye Comfort
eyetamins Vision Support
eyetamins blue blocker gummies
The Dry Eye Drink - Mixed Berry Flavor
The Dry Eye Drink - Orange Flavor
The Dry Eye Drink PM - Orange Flavor
myze Plus Routine
OPTASE Moist Heat Mask
OPTASE Dry Eye Intense Drops
OPTASE Dry Eye Spray
OPTASE HYLO Night Eye Ointment
OPTASE MGD Advanced Preservative Free Dry Eye Drops
myze Total TTO Routine
iVIZIA Preservative Free Dry Eye Drops
iVIZIA Dry Eye Night Gel Single Use Vials
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