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:
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