New Neurolens KOL Registration Form
Please fill out all the information below:
Contact Information:
Full Name
*
First Name
Last Name
Practice Name
*
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number to Reach You
*
Format: (000) 000-0000.
Best E-mail Address to Reach You
*
example@example.com
Practice/ Service Specialties
Please upload the following: --Completed W-9 -Latest Headshot -Shareable Biography
*
Browse Files
Drag and drop files here
Choose a file
Download W-9 Form - https://www.irs.gov/pub/irs-pdf/fw9.pdf
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of
Primary Affiliation
*
Vision Source
IDOC
PECAA
Acquios Alliance
Vision Trends
Opti-port
Keplr
Cleinman
HG Vision
Power Practice
EDO
Optic Gallery
Eye Care Centers
PERC
No Affiliation
Other Affiliation
Secondary Affiliation
*
Vision Source
IDOC
PECAA
Acquios Alliance
Vision Trends
Opti-port
Keplr
Cleinman
HG Vision
Power Practice
EDO
Optic Gallery
Eye Care Centers
PERC
No Affiliation
Other Affiliation
Preferred Communication Channel
*
Email
Text
Webinar
Phone Call
Which day of the week works best for large group meetings?
*
Monday
Tuesday
Wednesday
Thursday
Friday
What time of day works best for large group meetings?
*
8:00 - 10:00 AM
12:00 - 1:00 PM
5:00 - 8:00 PM
Preferred Support Activities
Large Group Presentations
Dinner Meeting Presentations
Virtual Calls
Commercial Initiatives and Special Projects
Additional Group/ Associations/ Society Memberships?
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