Form

Vendor Partnership

Vendor Form

Tell us about the product or service you are proposing to De-Lens Ophthalmics.

Product / Service Name *

Product Description

List Two Competitors to Your Product

Please provide details of your proposed pricing structure and available discounts.

Pricing Structure (Check all options that apply)
Purchase
Lease
Rental
Service Fee

Is the Discount Ongoing or One-Time?

Pricing Structure

Retail Product Cost

Until Which Date Is the Discount Available?

Discounted Product Cost

Help us understand how your product or service can benefit De-Lens Ophthalmics.

Will This Product / Service Produce Revenue for the Practice?

Will This Product / Service Save Money for the Practice?

Please Describe How the Product Produces Revenue or Savings

Provide any additional information you would like the De-Lens Ophthalmics team to consider.

Notes to the Practice from the Representative

Your information is submitted securely and will be handled confidentially by De-Lens Ophthalmics.