PRP Registration

Complete this form to to join the Physician Referral Program

Fields marked with an asterisk(*) are required.

First Name*

Last Name*

Suffix

Gender*

Practice Address*

Office Phone*

City*

State*

Zip*

FAX*

Email*

Mobile

Home

License

Physician
License #*

List state(s)
where licensed*

Do you participate
with Medicare?
Yes No

Physician
UPIN #*

Physician
NPI #*

Practice Specialties

Soft contact lenses
RGP contact lenses
Keratoconus RGP specialty
LASIK co-management
Cataract co-management
Refractive lens exchange co-management
Conductive Keratoplasty (CK) co-management
DSAEK co-management
Glaucoma co-management
Other

Comments

Please fill this section

Are you currently receiving our mailings?
Yes No
Is the above address new or recently changed?
Yes No
Are you currently participating in the REI “Physicians Referral Program”?
Yes No
Would you like your consultation reports expedited via e-mail?
Yes No
Would you routinely like a video of your patient’s surgery?
Yes No
Please indicate if you want a DVD of the patient surgery.
Yes No

Suggestions or recommendations to better fit your needs:

How can we help you grow your practice?

Type a desired username and password in the box below

Username

Password

Confirm Password

Rand Eye Institute reserves the right to refuse any application for initial or renewed membership. Rand Eye Institute shall be under no obligation to explain the reason for any refusal to grant or renew membership.

We do not give, share, sell, or transfer any personal information to a third party unless required by law. Please review REI's PrivacyPolicy

Rand Eye Institute, Deerfield Beach, Florida
1-800-782-1711 referral@randeye.com