Account Registration Form

In order for us to create your account, please complete all the information below. Please double check all information for accuracy before submitting as any errors or missing information will delay onboarding.

Does anyone in your clinic have an EyecareLive account?*

Yes

If yes, please list who:

Main Point of Contact:

Salutation*

First Name*

Last Name*

Email Address*

Direct Number*

ABB Account Info:

Account #*

ABB Representative/Point of Contact

EMR/EHR*

Clinic Information:

Clinic Name*

Clinic Phone Number*

Website URL*

Clinic Description (Short description or tagline to be displayed on app)*

Clinic Address*

City*

State/Region*

Zip Code*

Country/Region

Additional Locations

Include: Location name, and address. One location per line.

Doctor Information:

Please Note: This section is for billing purposes only. Please only include information for doctors who will be using the platform.

For example, you may be a multi doctor practice but only one doctor may be using Telehealth services, only include the doctor who will be paying for a subscription to EyecareLive. Our system is designed to bill for each doctor listed below.

Doctor 1:

Doctor 1 Name*

Doctor 1 Email*

Doctor 1 Title*

Doctor 1 NPI Number / Practitioner ID*

Doctor 1 State(s)*

Doctor 1 License Number*

Doctor 1 License Expiration *

Year/Month/Day

Doctor 2:

Doctor 2 Name

Doctor 2 Email

Doctor 2 Title

Doctor 2 NPI Number / Practitioner ID

Doctor 2 State(s)

Doctor 2 License Number

Doctor 2 License Expiration

Year/Month/Day

Doctor 3:

Doctor 3 Name

Doctor 3 Email

Doctor 3 Title

Doctor 3 NPI Number / Practitioner ID

Doctor 3 State(s)

Doctor 3 License Number

Doctor 3 License Expiration

Year/Month/Day

Additional Doctors

Include: Name, OD/MD, Email, NPI number / Practitioner ID, State(s) License Number, and Expiration Date. One doctor per line.

Staff Information:

Please include an email address designated for the EyecareLive Admin account. You will use this account to customize initial settings for the practice.

Please Note: The Admin email must be different than your doctor email.

Staff Admin Name*

Staff Admin Email*

Staff 2 Name

Staff 2 Email

Staff 3 Name

Staff 3 Email

Additional Staff

Include: Name, and Email. One Staff Member per line.