Email Address

We'll use this email to send you details and updates about your order and to establish an account in the EyeQue system.

Phone Number

First Name

Please provide your first name.

Last Name

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Street Address

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City

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Country

State

State/Province

Postal Code

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Referral Code

Discount Code

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Credit or debit card

✅ Confirmation

Thank you for your order!

Let's get you set up in EyeQue's system so that you may start using your VERAI package.

What is your gender?

Date of Birth

Please create a password

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👓 Current Prescription

How would you like to provide your current prescription information?

Please enter the values from your existing prescription below.

	SPHERE	CYLINDER	AXIS
Right Eye (OD)
Left Eye (OS)

Date	Please enter the date the prescription was issued.
Prescriber	Please enter the name of the doctor or clinic that issued the prescription.
PD

Please click the button below to upload a file from your computer. Once you have selected the file, click "Submit" to upload your prescription. You may upload a PDF, JPG, GIF or JPG file.

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✅ Confirmation

Thank you for your order!

✅ Login Successful

👓 Current Prescription

How would you like to provide your current prescription information?

Please enter the values from your existing prescription below.

Please click the button below to upload a file from your computer. Once you have selected the file, click "Submit" to upload your prescription. You may upload a PDF, JPG, GIF or JPG file.

Vision and Medical History

I have:

I am currently experiencing:

I have a history of:

Tobacco Use

Alcohol Use

Daily Medications

Allergies

Primary Provider Contact