MyTitle

Register to Become a Vital Tears Provider

Complete the form below to become a Vital Tears provider.
Each physician within the clinic will be assigned a username, which requires a unique email address.
A clinic username will be assigned to the primary contact by Vital Tears.
Once submitted, a member of our Vital Tears team will personally follow up.

Clinic Information

CLINIC NAME *

Address *

Street Address *

City *

State *

ZIP Code *

PHONE *

FAX

Primary Clinic Coordinator *

Primary contact for Vital Tears such as an office administrative assistant, scheduler, nurse or scribe.

First Name *

Last Name *

Phone

(Provide mobile contact or direct line if available)

Email *

*Check the box if you are a physician and will be the only Vital Tears contact.

Office Hours

Monday

from

Tuesday

from

Wednesday

from

Thursday

from

Friday

from

Saturday

from

Physicians

Enter the name, license and contact information for each physician at this clinic location. Each physician must have a unique email address.

Additional Coordinators

Enter the name and contact information of any additional coordinators, along with the name(s) of the physician(s) they serve (or "all" if applicable). This could be an office administrative assistant, nurse or scribe. Please do not re-enter a physician's name as the coordinator.

Blood Collection

Vital Tears partners with a network of blood collection facilities and a mobile phlebotomy service.

Are you interested in doing blood collection for your Vital Tears patients at your office? *

Yes *(A Vital Tears representative will contact you with details.)*

General

HOW EXPERIENCED ARE YOU (or your physician) WITH ORDERING SERUM EYE DROPS? *

Very experienced

Somewhat experienced

Not experienced at all

How many severe dry eye patients do you (or your physician) see each month? *

HOW DID YOU HEAR ABOUT VITAL TEARS? *

COLLEAGUE’S NAME *: