Eye Care Professional (ECP) Registration

Practice Information:

Ordering ECP's Information:

Office Point Of Contact:

Additional ECPs (Optional) - Name, Email, Mobile:

How Did You Hear About Us/Comments

Are you affiliated with Vision Source, the VA or DoD?

I agree to receive promotional emails, including special offers, product updates, and exclusive discounts from Regener-Eyes. I can unsubscribe at any time.

Opt-In for SMS Marketing

By checking this box, I consent to receive automated marketing by text message. Consent is not a condition to purchase. Message and data rates apply. Opt-out by texting STOP. View Privacy Policy.

Return to Store

This form is for Recommending Professionals to create an account to purchase/recommend Regener-Eyes.

Please be advised that all Recommending Professionals accounts are subject to a verification process before activation. We appreciate your understanding and cooperation as we ensure the integrity and authenticity of each account for the benefit of our users.