BSM Connection™ for Ophthalmology Registration

BSM Connection™ for Ophthalmology Registration Information

The cost for this annual subscription is $995.

As soon as we have processed your credit card information, you will receive a confirmation that your username and password have been activated. Thank you.

You MUST USE the TAB KEY to forward to the next field. DO NOT use the ENTER KEY.

Practice Information
*Practice Name  
*Practice Mailing Address line 1  
Practice Mailing Address line 2 
*Zip/Postal Code  
*Telephone  (ex., 333-444-1234)  
*Doctor's First Name   *Last Name   
*Doctor's Email Address  
Office Manager's First Name     Last Name  
Office Manager 's Email Address  
You need to create a UNIQUE username and password to enter the site.
*Your Preferred Username
*Your Preferred Password (password not to exceed 11 characters)
*Retype Your Password
*How did you hear about us?
       * - indicates required field