1
What is your phone number?
*Please provide your phone number and not your practice location*
OK
2
What is your profession?
A
Optometrist
B
Ophthalmologist
C
Family doctor
D
Nursing care
E
Other
OK
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3
If other, specify
OK
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4
Name of the main practice location
OK
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5
Address of the main practice location
Adress
Postal code
City
Province
Countries
OK
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6
Main Practice Location Contact Information
FAX number
Phone number
Email
OK
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7
Exercez-vous votre profession sous une incorporation ou en tant que travailleur autonome non incorporé?
Cette question est posée afin de déterminer les modalités de paiement de vos honoraires de cogestion.
A
Incorporation
B
Travailleur Autonome
OK
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8
Quel est le nom de votre entreprise?
OK
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9
Adresse de Facturation
Adresse qui figurera sur vos confirmations de paiement des honoraires de cogestion.
Adresse
Code Postal
Ville
Province
Pays
OK
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10
How would you like to receive consultation reports from your patients?
A
Email
B
FAX
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Thank you! Your submission has been received!
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