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PRIMARY CONTACT INFO

Please fill in all information accurately to ensure you are properly added to our network. You can have a maximum of (2) adults and (5) kids per patient account within our network. The 'primary' account holder will be responsible for the vision plan agreement. Please provide accurate information.

Primary First Name

Primary Last Name

Primary Email

Primary Phone Number

Primary SSN

Primary License #

Primary Address

Primary City

Primary DOB

Primary Zip Code

+ ADD ADULT

+ ADD KIDS

SECONDARY CONTACT INFO

Secondary First Name

Secondary Last Name

Secondary Email

Secondary Phone Number

Secondary DOB

+ ADD KID

KIDS

(1) First Name

(1) Last Name

(1) DOB

+ ADD KID

(2) First Name

(2) Last Name

(2) DOB

+ ADD KID

(3) First Name

(3) Last Name

(3) DOB

+ ADD KID

(4) First Name

(4) Last Name

(4) DOB

+ ADD KID

(5) First Name

(5) Last Name

(5) DOB

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Accept Messaging and Notifications Terms

You are joining the DirectOD / DirectVision network and opting into sms/email alerts and messages from our staff and your registered doctor. Standard message and data rates may apply. You can opt-out of messaging by clicking unsubscribe at the bottom of your email or replying STOP to sms messages. To read about our terms of service click here (TERMS OF SERVICE). To read our privacy disclosure click here (PRIVACY POLICY).

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