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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.
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

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.

Coordinators

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

Please choose Primary Contact person for the clinic *

Would you like a Clinic Username assigned to your practice?

This will allow support staff to log in and create orders on behalf of various physicians within the clinic.

Yes

Blood Collection

WHERE WILL BLOOD BE COLLECTED? *

Outside facility

At clinic (in-house)

General

HOW EXPERIENCED ARE YOU WITH ORDERING SERUM EYE DROPS? *

Very experienced

Somewhat experienced

Not experienced at all

How many severe dry eye patients do you see each month? *

HOW DID YOU HEAR ABOUT VITAL TEARS? *