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Thank you for your interest in Keeler products.
This form must be completed in its ENTIRETY to create an account with Keeler USA.

Please note that Keeler USA only services the EYE CARE industry. We cannot supply you if your business is not within this sector.

Billing information:
Your name or facility name
Legal business name
Address:
Street address
City
State
Zip
Phone:
Email address:
Payment terms requested:
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Tax exempt:
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Tax exempt number
A hardcopy of your exemption form will be requested and you must provide this before we can verify your account application.
Shipping address (if different to billing): 
Your name or facility name
Name of practice
Is this a residential address?
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Address:
Street address
City
State
Zip
Customer shipping account
if requested
Accounts Payable contact:
Name:
Last
First
Phone:
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General information:
Please answer all questions
Physician state license number:
Students are exempt
Physician specialty:
Anticipated number of patients seen monthly:
Anticipated monthly value:
I would like to enroll in Keeler's 20/20 rewards program to earn points with every clinical purchase, which can be collected and redeemed against brand new ophthalmic equipment. We will contact you occasionally with account statements or relevant program updates and you can unsubscribe at any time.
I would like to opt in to receive occasional marketing emails from Keeler with promotions, business news and new product availability. We promise to never pass your details on to a third party and you can unsubscribe at any time.

Please note products can only be sold to licensed medical personnel. If you are not a licensed medical professional your order will not be processed.