You will receive a confirmation email once your account has been approved. For faster service, email info@1-800-optisource.com or call 1-800-OPTISOURCE (678-4768) M-F 9am-5pm EST. OptiSource services eyecare professionals and registered businesses only. If you are a consumer, your request for a new online account will be declined.

Business Information

Business Name

Federal Tax ID # (EIN)*

9-digit code (no spaces)

Address 1

Address 2

(optional)

City

State

Zip Code

Business Phone

Dr. Alliance Group

Dr. Alliance Account Number*

Doctor's Name

(optional)**

License Number

(optional)**

License Exp. Date (mm/dd/yyyy)

(optional)**

*If you are an eyecare professional but are not part of a registered business, please contact us directly: 1-800-678-4768 | info@1-800-optisource.com

**Information required to process orders for pharmaceutical products.

Contact / Login Information

First Name

Last Name

Job Title

Mobile phone

(optional)

Work Phone

Email / Username

Password

Confirm Password

Security Question

Security Answer

How did you hear about us?

(optional)

Send me periodic emails and special offers

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