specialeyes
multifocal simulator
    
arc length calculator

Open an Account

To Design and Prescribe Custom Soft Contact Lenses

If you are an eye-care provider interested in opening a new account with SpecialEyes,
please complete and submit the form below. Alternately, you may call us at
866-404-1060
to create an account.

Practice/Business Name
Main Doctor or Licensed Optician Name
OD
MD
LDO
How many doctors or contact lens fitters are in the practice(s)?
Please list additional doctor's names (if applicable):
OD
MD
OD
MD
OD
MD
OD
MD
OD
MD
OD
MD
OD
MD
Contact Lens Technician
Billing Address
Shipping Address
Phone
Fax
Email
How did you hear about us?
Do you prescribe hybrid lenses?
Y
N
Do you prescribe lenses for corneal refractive therapy
CRT) or orthokeratology (Ortho-K)?
Y
N
Do you prescribe multifocal lenses?
Y
N
Do you prescribe scleral lenses?
Y
N
Does your practice have multiple locations?
Y
N
Place Your First Order (optional):
Patient's Name
OD K Readings
OS K Readings
OD Manifest Rx
OS Manifest Rx
Lens Type
Multifocal contact lens only:
Eye Dominance:
Pupil Size (2.0 to 6.5 in 0.5mm increments)
Pupil Size measurement recorded in what type of light:
Add Power
By submitting this form you're requesting to open an account with us. We respect your privacy and the protection of your personal data. You can learn how we handle information we collect by reading our privacy policy