Join the VIP Vision Care Program

First Name*
Last Name*
Date of Birth:
 / 
 / 
Sex:
Mailing Address:
Home Phone:*
-
Mobile Phone:
-
E-mail:
Occupation:

Employer Information

Company:
Company Website:
Company Address:
Office Phone:
-

Personalize your VIP Vision Discount Plan

We work with your primary insurances to maximize your benefits.

Primary Medical:
Primary Vision:

Dependents

Dependents are also covered under your VIP Vision Discount Plan.

Dependant 1:
Dependant 2:
Dependant 3:
Dependant 4:
Dependant 5:

To personalize your plan, check the services that may interest you.

Interested In:
How did you hear about us?

Terms & Conditions

The VIP Vision Plan is not a vision or health insurance product. Pricing and product availability are subject to change. The plan can be terminated at any time. Providers reserve the right to refuse service to individuals who do not properly qualify. The refractive surgeon is independent and is not an agent or employee of Dr. Kopolow, Dr. Girisgen, LensCrafters, or PearleVision. This plan cannot be used in conjunction with other special offers.

Accept Terms:
By selecting yes and entering your name in the field below you hereby digitally sign and agree to the Terms of Use.*
Digital Signature:*
Word Verification:

Join Now
& Start Saving on Eye Care!

Join Now