subject_line
Business Information
Your Name
*
Who do we contact at your office
*
Email
*
Number of Practice Locations
*
One
More Than One
Do you prefer:
*
Centralized billing for all locations with multiple dropship locations
A separate account with separate billing set up for each location
Single Location Information:
Business Name:
*
Street Address
*
Address Line 2
City
*
State/Province/Region
*
Zip/Postal Code
*
Phone Number
*
Fax Number
*
Country
*
Multiple Location Information:
Business Name (Primary Location):
*
Street Address (Primary Location)
*
Address Line 2 (Primary Location)
City (Primary Location)
*
State/Province/Region (Primary Location)
*
Zip/Postal Code (Primary Location)
*
Phone Number (Primary Location)
*
Fax Number (Primary Location)
*
Country (Primary Location)
*
Multiple Location Information (Cont):
Business Name (Location 2):
Street Address (Location 2)
Address Line 2 (Location 2)
City (Location 2)
State/Province/Region (Location 2)
Zip/Postal Code (Location 2)
Phone Number (Location 2)
Fax Number (Location 2)
Country (Location 2)
Multiple Location Information (Cont):
Business Name (Location 3):
Street Address (Location 3)
Address Line 2 (Location 3)
City (Location 3)
State/Province/Region (Location 3)
Zip/Postal Code (Location 3)
Phone Number (Location 3)
Fax Number (Location 3)
Country (Location 3)
More than 3 Locations
*
Yes
No
A Valley Contax new accounts representative will
contact you for all location information.
Staff
Doctor Name #1
Email Doc #1
License Number Doc #1
*
Doc Type #1
OD
MD
other
Doctor Name #2
Email Doc #2
License Number Doc #2
Doc Type #2
OD
MD
other
Doctor Name #3
Email Doc #3
License Number Doc #3
Doc Type #3
OD
MD
other
Contact Lens Tech Name #1
Email Tech #1
Contact Lens Tech Name #2
Email Tech #2
Contact Lens Tech Name #3
Email Tech #3
Accounting
Do you handle your accounts payable Internally or Externally
*
Internal
External
Accounting Contact
*
Phone Number Accounting
*
Notice: By default, we will E-Mail all patient invoices and your monthly statement to who you designate below:
E-Statement E-Mail Address #1
*
E-Invoice E-Mail Address #1
*
E-Mail for Shipment Notifications
🛈
E-Statement E-Mail Address #2
E-Invoice E-Mail Address #2
Type of Business
*
Clinic
Hospital
School
Other
Please Specify if "Other":
*
Type of Ownership
*
Corporation
Partnership
Sole Proprietorship
Other
Tenure at Present Location
*
Applicant Signature
Applicant Signature
*
clear
Name of Signee
*
Title of Signee
*
Other Info
How did you hear about Valley Contax
*
Colleague
Student
Internet Search
Mailing
Newsletter
Try Not 2 Blink Podcast
Other
Colleague's Name
*
Student's Name
*
Other Method
*