Register Your Ocutech Device

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Email*

Phone

Date of Birth

Male or Female?

Device Being Registered (Choose one)*

Date Received*

Prescribing Doctor*

Doctor's City*

Doctor's State*

What is the diagnosis for your vision difficulty?

What is your primary goal for use of your Ocutech system?

What is/are your secondary goal(s) (if any) for use of the device?

We welcome your comments:

May we share your comments on our website and on social media? We will NEVER share your name or contact information.

Would you like to be updated when new Ocutech products become available?

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Register Your Device