Eyecare Business
  Eyecare Business is free to qualified professionals. Summary Description
  To apply for a FREE subscription to Eyecare Business, please answer ALL of the questions on the form below.
  The publisher determines qualification and reserves the right to limit the number of free subscriptions.
  Geographic Eligibility: USA


 
1. Do you wish to receive a FREE subscription to Eyecare Business?
Yes     No


First Name:
Last Name:
Job Title:
(Ex: Director, Vice President, Project Manager, etc.)
Company:
(Please provide your Company Name in full: abbreviations could disqualify you)
Street Address:
Division/Mail Stop:
City:
State:
Country:
(Note: If your country is not listed above, subscriptions are not currently available at your location.)
Zip/Postal Code:
Business Phone:
Business Fax:
Email Address:
(Note: Valid email address is required or you could be disqualified.)

  What is the approximate number of employees in your company? (select only one)
 
Yes, please auto-fill my contact information for other publication qualification forms.


2. May we contact you via email?
Yes     No


3. May we contact you via email on behalf of ophthalmic industry on topics pertinent to you?
Yes     No


4. May we contact you via fax?
Yes     No


5. Please check the ONE category that best describes your business/professional activity: (select only one)
DISPENSING OPTICIAN OPTOMETRIST cont.
Self-employed/owner Independent affiliated with retail corporation
Employee of retail corp(chain) Employee with retail corporation
Employee of independent optician Employee of O.D.
Employee of independent O.D. Employee of M.D.
Employee of independent M.D. Other optometrist (please specify)
Other dispensing optician (please specify)
OPHTHALMOLOGIST
OPTOMETRIST OPTICAL LAB/WHOLESALER
Solo practice EXECUTIVE/BUYER AT CHAIN HEADQUARTERS
Group practice OTHER (please specify)
Corporate franchise


6. What is the wholesale price range of the majority of the eyeglasses sold at your business? (select one only)
Over $150 $51 - $100
$100 - $150 Under $50


7. At your practice, of the spectacle lenses you dispense, what percentage are A/R coated?
%


8. What are the lens processing capabilities on-site at your business? (select all that apply)
Finishing (edging) Surfacing
Casting None


9. Do you buy, specify, approve or influence the purchase of contact lenses?
Yes     No


10. Do you fit contact lenses?
Yes     No


11. In lieu of a signature, we require a personal identifier. To verify that you submitted this application please enter below in what state were you born:


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  Please select the preferred format:
  Which of the following best represents the primary business of the company with whom you are employed?
Please Specify for Other:
  Which of the following best describes your title?
Please Specify for Other:
  What is your facility's average bed size?
  What is your role in purchasing decisions?
  Are you on a product evaluation committee? Yes     No
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Copyright © 2009 Eyecare Business, All Rights Reserved.