IVI Quick Start Registration Form

Vision Therapy Quick-Start Course Registration

Please fill out the entire registration form. This registration form is hosted by JotForm, and the transaction is processed by Stripe. Both JotForm and Stripe use 256 bIt SSL (Secure Socket Layer) connections and are PCI DSS Service Provider Level I certified. Thank you!
Name*

First NameLast Name
Title

O.D.TherapistManagerAssistantOther
Practice Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Phone Number*

Area CodePhone Number
E-mail*
Names of Doctors, Therapists, and Staff Attending
Best number to reach me

Area CodePhone Number
Best day(s) to reach me

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Best time(s) to reach me

8am-10am10am-12pm12pm-2pm2pm-4pm4pm-6pm6pm-8pm
I have a comment or question.
I would like to receive occasional emails from IVI.

Yes. Sign me up.
How I heard about the workshop.

Web SiteFriend/ColleagueOnline SearchEmail
To complete your registration, select the Attendees and complete the payment information. Major credit cards are accepted.

My Products

First Doctor$3,200.00

Second Doctor$1,550.00

Quantity

First Therapist$1,600.00

Additional Staff$1,100.00

Quantity

Total $0.00

Vision Therapy Quick-Start Course Registration