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🛒 Checkout

Patient and Shipping Information

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

✅ Review

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Contact Information

Sending VERAI bundle to:

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{{newUserData.city}}, {{newUserData.state}} {{newUserData.postalCode}}

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{{newUserData.email}}


Your Cost: ${{ formatPrice( lookupPrice('VERAI')) }} (plus {{formatPrice(lookupShipping('VERAI')) }} shipping. )

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Payment Information

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✅ Confirmation

Thank you for your order!

✅ Login Successful

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Vision and Medical History

Please fill out the following form. This information will be used by the eye care professional.

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Last Eye Exam

I have:


I am currently experiencing:


I have a history of:


Tobacco Use

Alcohol Use


Daily Medications

Allergies


Primary Provider Contact