Product Registration

Note: Registration must be completed within 15 days of purchase for warranty to be effective.

Name*
First Last
Purchase Date*
MM slash DD slash YYYY
Practice*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Product*
- EpiGlare Single Phoroptor Kit
- EpiGlare Handheld Kit
- EpiGlare Binocular Phoroptor Kit
Serial Number(s)*
Distributor
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