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PRIMARY CONTACT INFO

Please provide accurate information to ensure proper enrollment. Each account may include up to 2 adults and 5 children. The primary account holder is responsible for the vision plan agreement.

First Name

Last Name

Mobile Number

SSN

License Number

Address

City

DOB

Zip Code

+ ADD ADULT

+ ADD KIDS

SECONDARY CONTACT INFO

First Name

Last Name

Phone Number

DOB

+ ADD KID

KIDS

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

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).

PRIMARY CONTACT INFO

Please provide accurate information to ensure proper enrollment. Each account may include up to 2 adults and 5 children. The primary account holder is responsible for the vision plan agreement.

First Name

Last Name

Phone Number

SSN

License Number

Address

City

Zip Code

DOB

+ ADD PERSON

+ ADD KIDS

SECONDARY CONTACT INFO

First Name

Last Name

Phone Number

DOB

+ ADD KID

KIDS

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

DOB

+ ADD KID

First Name

Last Name

DOB

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Accept Messaging and Notifications Terms

PRIMARY CONTACT INFO

SECONDARY CONTACT INFO

KIDS

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PRIMARY CONTACT INFO

SECONDARY CONTACT INFO

KIDS

ALL RIGHTS RESERVED BY DIRECTVISION

PRIMARY CONTACT INFO

SECONDARY CONTACT INFO

KIDS

ALL RIGHTS RESERVED BY DIRECTVISION

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SECONDARY CONTACT INFO

KIDS

PRIMARY CONTACT INFO