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New Doctor Form
Personal Information
Full Name
*
Date of Birth
*
Mailing Address
*
Social Security Number
*
City & State of Birth
*
Cell Phone
*
Email Address
*
Bank Name
*
Routing Number
*
Account Number
*
License Information
Licensed State(s)
*
Arkansas
Kansas
Kentucky
Missouri
Oklahoma
Other
NPI Number
*
Any period(s) of loss of license, Termination of Insurance Credentials, Etc.?
*
Documents
Please upload the following documents below. If you are licensed in multiple states, please upload all licenses in the Optometric License field. If you do not have a DEA#, please leave that field blank.
Optometric License
*
Click to choose a file or drag here
Malpractice Insurance
*
Click to choose a file or drag here
Professional Liability Claims (Current or Past)
Click to choose a file or drag here
Completed W9 (
Click Here
to fill out)
*
Click to choose a file or drag here
Driver's License or Passport
*
Click to choose a file or drag here
Miscellaneous Certifiications (if applicable): i.e. DEA, Laser License, and any other certifications you wish to include.
Click to choose a file or drag here
Please sign below to indicate you have completed this form accurately to the best of your knowledge. We will also use this signature to print on prescriptions.
Signature
*
Signature
Submit