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Contact Registration:

After completing the registration form, you will be contacted by a Member of the National Coalition directly if your state does not have an IPA membership.

Otherwise, you'll be contacted by your state IPA to learn more about how we can join together for our mutual benefit.

Please fill out the following as completely as possible. Then, click the "Submit" button to send the information.

Title

First Name*

Middle Initial

Last Name*

Suffix

Address*

Address (cont)

City*

State*

Zip

E-mail*

Questions and/or Comments:

I Am A:

Consumer seeking information on finding an IPA member in my state
Vendor interested in a strategic partnership with the National Coalition
Practitioner in a state without an IPA
Member of a state IPA


Please give us some information about your practice
Practice Name
Optical Name
Practice TIN#
License #
Office Phone
Office Fax
Website
Days
Hours
Services

Please enter your e-mail and choose a password; your e-mail password will become your login username. Also, please provide information about any other accounts you may have.
Password*
Re-Type Password*
	I wish to receive occasional newsletters from The National Coalition
X-Cel Account #
ELOA Account #
VisionWeb Account #
Safilo Account #
Clear Vision Account #
Signature Account #

When you are ready, click Submit to send your information. Please make sure you have completed all fields marked with an "*".