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Website VIP (Very Important Patient) Registration To become a registered VIP with our office, please fill out the form below. Once your membership has been activated, you will be notified via email. Please make sure the email address you provide is accurate. Please note we respect your privacy, and will not loan, sell, or otherwise distribute your personal information to any third party. Fields marked with an * are required for registration. General Information: *First Name: _______________________________ *Last Name: ______________________________ *Address: ____________________________________________________________________________ *City: _______________________________ State: _________ *Zip: __________ *Phone: _____________________________________ Fax: ____________________________________ *Email Address: ______________________________________________________________________ Birthday: __________ / __________ / __________ Member Log-In: Specify desired username and password for website access *Username: ___________________________ *Password: ____________________________ ❒ I prefer not to receive coupons, VIP event invitations and a complimentary subscription to the Healthy Vision Newsletter. ❒ I prefer not to receive appointment reminders to schedule my eye examination via email. ❒ I prefer not to receive an e-card on my birthday.

Website VIP (Very Important Patient) Registration · Website VIP (Very Important Patient) Registration To become a registered VIP with our office, please fill out the form below

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Page 1: Website VIP (Very Important Patient) Registration · Website VIP (Very Important Patient) Registration To become a registered VIP with our office, please fill out the form below

Website VIP (Very Important Patient) Registration

To become a registered VIP with our office, please fill out the form below. Once your membership has been activated, you will be notified via email.

Please make sure the email address you provide is accurate.

Please note we respect your privacy, and will not loan, sell, or otherwise distribute your personal information to any third party. Fields marked with an * are required for registration.

General Information:

*First Name: _______________________________ *Last Name: ______________________________

*Address: ____________________________________________________________________________

*City: _______________________________ State: _________ *Zip: __________

*Phone: _____________________________________ Fax: ____________________________________

*Email Address: ______________________________________________________________________

Birthday: __________ / __________ / __________

Member Log-In: Specify desired username and password for website access

*Username: ___________________________

*Password: ____________________________

❒ I prefer not to receive coupons, VIP event invitations and a complimentary subscription to the Healthy Vision Newsletter.

❒ I prefer not to receive appointment reminders to schedule my eye examination via email.

❒ I prefer not to receive an e-card on my birthday.

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