Register with Visioncare

Please complete the form below to register with Visioncare.

Note: * denotes a required field.

Please choose your employer from the dropdown below

Employer / Association
Title *
First name *
Surname *
Address *
Region *Please choose a region, district and suburb close to where you would like your optician to be. (Possibly close to your home or work). If the Suburb field shows All Suburbs this means it covers the entire city.
District
Suburb
GenderMale Female
Date of birth *
Email *
Home Phone
Cell phone *
Work phone Ext:
Are you experiencing any vision problems? Yes No
Do you wear glasses? Yes No
What do you use them for?
What type of lenses do you wear?
Do you require safety glasses? Yes No
Do you have prescription sunglasses? Yes No
Do you need prescription sunglasses? Yes No
Do you wear contact lenses? Yes No
When was your last eye exam?

Do you have family members who you think would like to receive the benefits of Visioncare? If so fill in the fields below:
Add family members:
Email my family members:
Print a faxable form:
Post me an application to the address already provided:
I consent to receive email replies from Visioncare at the email address provided.