National Lens - America's Leading Discount Lens Distributor

Account Information

Customer Account Information
(* = Required Field)
New Account -- Please fill out required fields and hit Submit to create an account.

* Business Name:

* Primary Phone:

* First Name:

Work Phone:

* Last Name:

Fax:

Referred By:

Physician Information

* Physician Type		* License / Federal ID #

Please Note: If you are not an Optometrist, Ophthalmologist, or Optician, you will not be able to purchase product from us.

Ship To Name:

* Billing Address:

Shipping Address:

* Billing City:

Shipping City:

* Billing State:

Shipping State:

* Billing Zip:

Shipping Zip:

* Billing Country:

Shipping Country:

* Business Email:	(Used for all business email communication.)
* Account Email:	(Used for Login and Account Maintenance--can be same email as above.)
* User Login:
* Password:
* Password (Confirm):
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Order Information and History