Optima Patient Referrals

Everyday Optima receives requests from web site visitors for referrals to retail locations that carry Optima's HyperView®, HyperIndex® and POLRTEC® 1.67 lenses. Use the form below if you would like to become a distributor for Optima lenses or if you currently sell Optima lenses and would like your store to be added to Optima's web site patient referral program.

Please send me information on becoming a distributor for Optima lenses.

We currently sell Optima lenses. Please add our store to your referral list.

Your Name:

Phone:

Store Name:

Fax: # of Store Locations:

Address:

City: State: Zip:

Current Optical Lab Used:

Acct. #:

Lab Address:

City: State: Zip: