Request Information

Thank you for your interest in The Refractive Surgery Consultant™ Elite software program.

For more information or to purchase the program, please complete the form below. You will be contacted by email regarding your request. Therefore, be sure to include an accurate email address.

To Purchase the Refractive Surgery Consultant (TM) Elite CLICK HERE to obtain a printable Purchase Order Form. (You will need Acrobat Reader to view/print this form) Please make certain the Refractive Surgeon Signs the completed Purchase Order Form and mail the form along with your payment check to:

Refractive Consulting Group, Inc.
28071 North 90th Way

Scottsdale, Arizona   85262
Phone: +1-480-664-1800

Facsimile: +1-480-664-1881

Registrant is a(an):

Practicing Refractive Surgeon
Administrator\Office Manager Refractive Coordinator
Optometrist
Individual Other than Above Looking for General Information about the program

About your practice?

Solo Practice
Group Practice 2-5 Surgeons
Group Practice 6 or more Surgeons
I am not associated with any practice.

May we send Email Updates about The Refractive Surgery Consultant™ 2000?

Yes
No, Send by Mail or Facsimile Only
No, I will contact you should I require additional information

My practice performs...

10 - 50 Refractive Procedures a Month
51 - 100 Refractive Procedures a Month
More than 100 Refractive Procedures a Month
No Refractive Procedures

Contact information:

Name
Name of Practice
Street Address
Address (cont.)
City, State
Country
Zip/Postal Code
Phone
FAX
E-mail

Comments: