Signup now for your first WinkPad

Awaken your patients with the latest in educational technology and move your eye care practice to the next level!

Experience the power and excitement of WinkPad!

Watch it transform your patient’s next visit to their Eye Care Professional!

Become a new WinkPad member NOW!!!

Simply complete the form below and click "submit." Watch the screen to see if you qualify for immediate cost savings exceeding 50%!!!

Note: The initial promotional period for $99 WinkPad ended December 15, 2007.

PROFILE YOUR PRACTICE

Fields marked with * are required. Please use the address where WinkPad will be located.

Contact Information
Practice Name*
Address:*
Address 2:
City*
State / Prov.*	U.S. ------ AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Canada ------ AB BC MB NB NF NT NS NU ON PE QC SK YT
Zip Code*
Phone 1*	( )  ext.
Phone 2	( )  ext.
Fax*	( )  ext.
Doctor Contact Information
Doctor Name*	Mr. Ms. Mrs. Dr.
Doctor Email Address*
Doctor Phone*	( )  ext.
Doctor License Number
Contact Person (if different from Doctor)
Contact Name	Mr. Ms. Mrs. Dr.
Contact Email Address
Contact Phone	( )  ext.
Which selection best characterizes your practice?*
Independent Clinic Conventional Chain Mass Merchandiser Wholesale club Department Store HMO Hospital Refractive Surgery Optical Laboratory Other

How did you hear about the WinkPad™?*	20/20 Magazine Review of Optometry Magazine Vision Monday Other Publication... Jobson Sales Representative E-mail from Jobson Essilor Sales Force Zeiss Sales Force Shamir Sales Force Transitions Sales Force Balester Optical Sales Force Luzerne Optical Manufacturer's Representative Trade Show Optcom List Internet Search Engine Word of Mouth Other...
How many Doctors work at this location?*
How many Opticians work at this location?*

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