Cherry Optical Lab

Sales Representative Where Applicable (Required)

Business Owner Name (Required)

Business Name (Required)

DBA Name if Applicable

Business Street (Required)

City (Required)

State (Required)

Zip Code (Required)

Business Phone (Required)

Business Website

How did you find out about us?

Facebook Page

Primary Optical Contact #1 (Required)

Primary Optical Contact #1 Phone (Required)

Primary Optical Contact #1 Fax

Primary Optical Contact #1 Email (Required)

Primary Optical Contact #2

Primary Optical Contact #2 Phone

Primary Optical Contact #2 Fax

Primary Optical Contact #2 Email

Billing Contact Name

Billing Contact Phone (Required)

Billing Contact Email (Required)

Is your billing address different than your business address? (Required)

YesNo

Billing Street (Required)

City (Required)

State (Required)

Zip Code (Required)

Are you a provider for any of the following? If yes, select all that apply.

NeurolensNeuroVisual Medicine InstituteShaw

Order/Job Type (Required)

EdgedUncutBoth

All customers receive paper and e-statements. What email would you like these sent to? (Required)

Preferred Payment Method (Required)

Online PaymentsLab Payments via CC/ACH

What software are you currently using to order online? (Required)

DVI/RX WizardSpecCheckVision WebNot Ordering Online

If not online, how are you ordering? (Required)

Would you like more info on Electronic Ordering? (Required)

YesNo

Would you like physical or fillable PDF Order Forms? (Required)

YesNo

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