Co-Management Signup / Opt-in | LASIK.com™ Official Site

"*" indicates required fields

Have You Co-Managed With a LASIK Provider Before?*

Were you a member of the LASIKPartners Program?*

Who Have You Co-Managed With Before?*

Other Brand

Doctor Name*

Prefix First Last

Doctor Email*

This MUST be a Unique Email to you specifically. Our CRM does not allow us to have more than one contact with the same email address.

Doctor Phone*

Practice Name*

Practice Email

Practice Phone*

Practice Fax

Practice Address*

Street Address Address Line 2 City State ZIP Code

Geographic Market (City)*

Practice Primary Contact Name

First Last

Practice Primary Contact Email*

Practice Tax ID #*

W9 Form*

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Are You Associated With*

Co-Management Options*

Pre-Op Only

Pre and Post Op

Referral Only

What co-management options are you interested in?

How Did You Hear About This Program?*

Other

Comments

This field is for validation purposes and should be left unchanged.

Questions?