Tangible Care 2.0 Form

Tangible Care Enrollment and Prescription Verification
Complete this form to enroll in Tangible Care, an exclusive support program for scleral and other rigid gas-permeable contact lens wearers. After enrolling, you will be connected to a Care Coach to assist you with contact lens care and other questions.

To purchase Tangible Boost, we must verify that you have a prescription by obtaining your practitioner's unique Rx Code.
- The code is located on the Rx you were given by your practitioner
- No code? No problem! Enter your Eye Care Practitioner's name below, and we will assist in obtaining your Tangible Boost prescription
- After you submit this form you will receive an email confirmation with a link to purchase your practitioner's recommended solutions
Patient Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
YesNo
What is your practitioner's Rx Code
What is your contact lens type?*
Should be Empty: