Doctor and patient looking at an iPad in the exam room

Your Eyefinity Journey Starts Here

Let Us Show You Why Eyefinity Is the Perfect Fit for Your Pearle Vision Business

Discover how Eyefinity can help your business increase revenue and enhance patient care. Complete the form below, and our team will reach out to you within two business days.

Fields marked with an asterisk (*) are required for form submission. After submitting, you will receive a pop-up message at the top of the page confirming your success!

Please complete all of the information below.
If you only have one location, you can skip down to Territory Franchise Director.
If you only have one provider, you can skip down to Primary Objectives.
Please check any boxes that apply to your account.

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Legal Business Name *

Business Tax ID / Business Number *

Business NPI (N/A for Canada Locations)

Office Phone Number *

Office Fax Number *

Business Email *

Are you participating in EyeCon (supply chain benefits) with Pearle? *

Pearle Legacy Number *

Pearle AcuityLogic Number

Street *

City *

State/Province *

Zip or Postal Code *

Country *

2nd Location Pearle Licensed Operator Store #

2nd Location Business NPI

2nd Location Street

City

State/Province

Zip or Postal Code

Country

Territory Franchise Director Name *

Territory Franchise Director Phone Number *

Territory Franchise Director Email *

Office Manager Name *

Office Manager Phone Number *

Office Manager Email *

Point for Implementation Name *

Point for Implementation Phone Number *

Point for Implementation Email *

Licensed Operator Name *

Licensed Operator Phone Number *

Licensed Operator Email *

Primary Provider *

NPI # *

2nd Provider

NPI #

3rd Provider

NPI #

Primary Objectives (List All): Any special needs your practice may have

Interest in AcuityLogic Services and Products

PM System Conversion

Insurance Clearinghouse Integration (Gateway/TriZetto)

Worldpay Integration (Separate Contract)

Current Practice Management Software *

Interest in EHR in Eyefinity Encompass w/ SureScripts Services and Products

e-Prescribing

iPad

Desktop

Meaningful Use

Current EHR Software *

# of ODs

# of MDs

Existing Equipment Interfaces

Number of Locations *

Number of Full Time Doctors Per Location *

Number of Part Time Doctors Per Location

Number of Concurrent Users Per Location *

Number of Workstations Per Location

Are You a Two-Door State? *

Business Website Address