Total Vision Services



Regional Vision Plan Enrollment

Check All That Apply          
Discount Vision
 -  Group Rate - payroll deducted $30/year
 -  Individual Direct - home billing $35/year

* = required field
First Name: *
Last Name: *
Address: *
 
City *
State: *
Province
Zip:
DOB: * e.g. 01/01/1970
SSN:  *
Employer Name *
Employment Start Date: e.g. 01/01/1970
Email:
Phone: *
Fax:
Household Members: (excluding applicant)
Family Member #1:
Family Member #2:
Family Member #3:
Family Member #4:
Family Member #5:
Family Member #6:
Family Member #7:
Family Member #8:
Only complete the section below if your employer does not utilize payroll deduction
Name on credit card:
Credit card type:
Credit card number:
Expiration date:



  
   
THIS IS NOT INSURANCE.
Payment must be made at the time of service in order to receive a discount.