Inscripción / Opt-in de Cogestión | Sitio Oficial de LASIK.com™

"*" señala los campos obligatorios

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*

Prefijo Nombre Apellidos

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*

Dirección Dirección 2 Ciudad Provincia Código Postal

Geographic Market (City)*

Practice Primary Contact Name

Nombre Apellidos

Practice Primary Contact Email*

Practice Tax ID #*

W9 Form*

Tipos de archivos aceptados: jpg, gif, png, pdf, Tamaño máximo de archivo: 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

Este campo es un campo de validación y debe quedar sin cambios.

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