Video Recording Request (AOA 2023)

Register For Your Video Recording
Sender Name (backend)
Your Email*
Enter your email here to receive a copy of your filming submission.
Physician Name (First & Last)

Do not add additional details like MD, OD, etc. Only enter your first and last name.
First Name*
Last Name*
Physician Full Name (For Monday board)
Suffix*
For example: MD, OD, etc.
Physician Specialty
For example: Optometrist, Ophthalmologist, etc.
Practice Name
Appointment*
Date and Time (For backend)
Practice Logo

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Practice Web Address
Phone Number
Please enter a valid phone number.
Tradeshow
Should be Empty:

SPECIAL TearCare^® offer while you are at AOA 2023