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Sharing Vision Grant Program UltraHealth Practitioner Enrollment

Question Title

* Please enter your contact information:

Full Name: *

Practice Name: *

Practice Address: *

Practice Address 2:

City: *

State: *

ZIP: *

Email Address: *

Phone Number: *

SynergEyes Account Number:

Question Title

* Patient's Name

Question Title

* Terms and Conditions:

By checking "I Agree" you agree to participate in the Sharing Vision Grant Program offered by SynergEyes, Inc. SynergEyes shall provide SynergEyes brand contact lenses for free to your Practice. In turn, you agree to supply the lenses at no cost to the selected Sharing Vision Grant Program recipient, as well as waive any contact lens fitting fees. Practice agrees to participate in marketing and promotional activities associated with the Sharing Vision Grant Program requested by SynergEyes.

All terms and conditions of your existing SynergEyes "Practice Prescribe It!™ Agreement" remain effective and are applicable to the Sharing Vision Grant Program.

I Agree