New Client Application

As a member of our Visionary team, our goal is to help you build the quality and integrity of your specialty lens practice.

Practice Name

Owner

Practitioner’s Name

License #

Billing Address

Street Address

City

Zip Code

State

Phone #

Fax #

Email Address

Shipping Address

Street Address

City

Zip Code

State

Phone #

Fax #

Buying Group

How would you like to be billed?

Bill me through my buying group, provided details below. (15% Discount)

Bill me directly (Apply my buying group discount, provided details below - 15% Discount)

PECAA / PECAA MAX:

ABB OneBill

PERC

Vision Source

Yes

Vendor Reference

Name

Phone #

Account #

Name

Phone #

Account #

Bank Reference

Name

Phone #

Account #

Where did you hear about Visionary?

Name

First Last

Date