Vision Screener Order Form

Vision Screener Quote Request

Please fill out the following to request a quote and one of our associates will get back to you as soon as possible.

**Standard slide packages for the Optec 5000 Series include: Ophthalmic Prescreening, Michigan Preschool, H.O.T.V., Driver Rehabilitation, Industrial, and International.

**Standard test slides for the Optec 1000P include: Elementary, Secondary, and Multi-Acuity.

Vision Screener Order Form

Name *

First

Name *

Last

Company/Organization/Practice *

Account Number

Email *

Phone Number *

Address Line 1 *

Address Line 2

City *

State

Zip Code *

Country *

Products [Please specify product(s) to order]

Optec 5000 Screening System - code Optec 5000 (Specify 1 of the 6 standard packages** in Message/Requests.)

Quantity

Optec 5000P Screening System - code Optec 5000P (Specify 1 of the 6 standard packages** in Message/Requests.)

Quantity

Optec 5500 Screening System - code Optec 5500 (Specify 1 of the 6 standard packages** in Message/Requests.)

Quantity

Optec 5500P Screening System - code Optec 5500P (Specify 1 of the 6 standard packages** in Message/Requests.)

Quantity

Optec 5000PG REHAB Vision Screening System - code Optec 5000PG

Quantity

Functional Vision Analyzer - code Optec FVA

Quantity

Optec 1000P Vision Screening System - code 1000P

Quantity

Message/Requests

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