Discount Plan Application
 
VISION DISCOUNT PROGRAM
 
PRODUCTS INCLUDED: LASIK VISION CORRECTION,VISION
 
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Step 1: Member Information


*Required Fields
*First Name
*Last Name
*Mailing Address
*City
*State
*Zip Code
*Home Phone
Mobile Phone
*Date of Birth
*Gender
 
A valid e-mail address is required to communicate with you.
 
*E-mail Address
*Confirm E-mail Address

Dependent Information
Number of dependents (not including self)

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