Follow-Up Form (Providers)

Thank you for your interest in TheraSpecs! Before we can send you materials, we need just a few more details to verify what is best to send you. Please fill out the form below, and if you have any issues, you can email us at providers@theraspecs.com.

What kind of patients do you see and what type of conditions do they have?*

Approximately, what percentage of your patients wear prescription glasses regularly?*

How many other providers do you work with?*

Practice or organization name

Mailing Address Line 1*

Mailing Address Line 2

City*

State*

Zip/Postal code*

Do you have any additional questions about TheraSpecs?

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