Thank you for your interest in PFO Global. Please complete the form below to apply for a personal Access ID and Password. All applicants will be
notified by phone in three business days if approved.

PFO Global services are available for currently licensed private practice eye care professionals only. This includes optometrists, ophthalmologists,
and their office staff within an independent practice.


Please note, we do not accept registrations from patients/consumers. Our customers are optical professionals and businesses.
Business
Full Legal Business Name: *  
Tradename / D.B.A:
NPI:
Federal Tax ID: *
Business Type: *
How did you hear about us? (and other optional notes):
Physical Address: Your physical address is required for shipping purposes when ordering products from our partners.
They are unable to deliver to a P.O. Box.
Address Line1:*
Address Line2:
City: * State:*
Zip Code:*    
Phone Number:*
e.g. 123-123-1234
Fax Number:
e.g. 123-123-1234
  If Billing address is the same as your physical address, you may check this box to avoid retyping.
Billing Address:(All billing statements will be sent to this address)
Address Line1:*
Address Line2:
City: * State:*
Zip Code:*
Phone Number:*
e.g. 123-123-1234
Fax Number:
e.g. 123-123-1234
Contact Information:
First name:*
Middle:
Last name:*
Suffix:
Title:* (O.D., M.D., etc.)
Email:*
(PFO Global will not share your e-mail address or other information with any outside parties.)
User Name:*
Password:*
Case-sensitive. Must be at least 7 characters long.
Confirm Password:
Case-sensitive. Must be at least 7 characters long.  

* Indicates a required field

TERMS AND CONDITIONS:

Privacy and HIPAA Policy:
If applicants are found to be fraudulent or in unfavorable standing with any PFO Global business partner, the membership request will be denied and the credit card will not be charged. Any denial notices will be sent by letter within seven to 10 business days.

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