OcuTherm Practice Application (for Eye Care Practices)

Eye Care Practitioners / Staff Only: Please fill out the form below.
If you have any questions, please email ([email protected]) or call 1-855-628-8437

NOTE: You should receive an automated confirmation email from us within minutes after you submit the form below. If you do not see the confirmation email in your inbox, please check your spam folder!

Practice Name*

Your Name *

Your Position in the Practice*

Your Phone #*

Your Email*

Practice Website (if applicable)

Email of Person who will be Ordering Products, if different

Billing Address-1*

Billing Address-2

City*

Zip*

State*

Choose one:
YES, I AGREE TO THE TERMS OF AGREEMENT BELOW. Please set up an OcuTherm Account for my Practice.NO, I do not agree to the terms of agreement below.

We look forward to working with you!

Terms of Agreement
I agree that I will purchase OcuTherm products at wholesale prices for the sole purpose of reselling OcuTherm products through my business, at or above the MSRP (Manufacturer's Suggested Retail Price). I will not sell, or enable the sale of, any OcuTherm products on Amazon, eBay, or other third-party seller sites, although I may sell OcuTherm products through my own business' linked web store.

REMEMBER, You should receive an automated confirmation email from us within minutes after submitting the form.
If you do not see the confirmation email in your inbox, please check your spam folder.